Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands in Guatemala
June 2014
FANTAFHI 3601825 Connecticut Ave., NW Washington, DC 20009-5721Tel: 202-884-8000 Fax: 202-884-8432 [email protected] www.fantaproject.org
This report is made possible by the generous support of the American people through the support of the Office of Health, Infectious Diseases, and Nutrition, Bureau for Global Health, U.S. Agency for International Development (USAID) and USAID/Guatemala, under terms of Cooperative Agreement No. AID-OAA-A-12-00005, through the Food and Nutrition Technical Assistance III Project (FANTA), managed by FHI 360. The contents are the responsibility of FHI 360 and do not necessarily reflect the views of USAID or the United States Government. June 2014
Recommended Citation
FANTA. 2014. Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands in Guatemala. Washington, DC: FHI 360/ FANTA. Contact Information
Food and Nutrition Technical Assistance III Project (FANTA) FHI 360 1825 Connecticut Avenue, NW Washington, DC 20009-5721 T 202-884-8000 F 202-884-8432 [email protected] www.fantaproject.org
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Acknowledgments
The following people were instrumental in the process of using Optifood to develop the evidence-based
dietary recommendations for children, pregnant women, and lactating women in the Western Highlands
of Guatemala and in the development of this report: Manolo Mazariegos (Instituto de Nutrición de Centro
América y Panamá [INCAP]) and Maggie Fischer, Camila Chaparro, Monica Woldt, and Gilles Bergeron
(Food and Nutrition Technical Assistance III Project [FANTA]) for the design of the protocol used to
collect the data to develop the food-based recommendations; Manolo Mazariegos, Ana Victoria Román,
Jorge Pernillo, Gladys Miranda, Maya Ferris, Blanca Sulecio, Nidia Ivette Patzán, Brenda Lorena
Castillo, Maura Hernández, Blanca Lidia Escobar, Deisy Dionicio Ruyan, Elia Yolanda Castillo, Maribel
Ortiz, and Toribia Lorenzo Hernández (INCAP) for data collection for the cross-sectional survey and
market prices surveys; Humberto Méndez, Vanessa Echeverría, and Lucy Mérida (INCAP) for processing
and analysis of cross-sectional survey data and for preparation of data for use in Optifood; Elaine
Ferguson (London School of Hygiene and Tropical Medicine [LSHTM]), Alison Tumilowicz and Maggie
Fischer (FANTA), and Manolo Mazariegos, Vanessa Echeverría, and Jorge Pernillo (INCAP) for
Optifood analysis; Alison Tumilowicz (FANTA), Elaine Ferguson (LSHTM), and Frances Knight and
Manolo Mazariegos (INCAP) for interpretation of Optifood results and writing of significant portions of
the report; and Maggie Fischer, Monica Woldt, Luisa Samayoa, Kali Erickson, Gilles Bergeron, and
Sandra Remancus (FANTA) for technical input and reviews of drafts of the report.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Preface
The promotion of appropriate complementary feeding has been identified as one of the most effective
strategies for reducing stunting and the associated burden of disease (Bhutta et al. 2008). The World
Health Organization (WHO) recommends that food-based recommendations (FBRs)1 be used in nutrition
education and communications to promote a diverse array of locally available and produced foods and
traditional foods where possible, and rely on introduced products or supplements only if they are able to
address critical nutrient gaps (WHO 2008a). The Optifood tool was developed to support the design,
identification, and testing of FBRs that are evidence based and population specific.
This report presents an analysis of data collected on local dietary patterns and food costs in the Western
Highlands of Guatemala and evidence-based and population-specific FBRs for children 6–23 months old,
pregnant women, and lactating women in the region. The report describes how the FBRs for the target
population groups were developed using the Optifood program and presents the final FBRs for
nutritionally adequate diets, including and excluding micronutrient supplementation. Finally, the report
provides an overview of expected or recommended actions, based on key findings of this project.
This document is complemented by a summary report, available for download in English or Spanish.2
This document is intended for readers who have knowledge of the processes and data used to conduct
dietary analyses in Optifood. A program manual with further information about Optifood, its data
requirements, and its functions will be available following the official 2014 launch of the software.
1 FBRs are dietary messages for members of the specified target group to promote consumption of specific foods or food groups.
They may also include the recommended frequency of consumption of the foods or food groups in a 1-day or -week period
(FAO/WHO 2001). 2 Spanish and English versions of the summary report are available at http://www.fantaproject.org/tools/optifood.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Contents
Acknowledgments ........................................................................................................................................ i
Preface .......................................................................................................................................................... ii
Abbreviations and Acronyms .................................................................................................................. vii
Executive Summary .................................................................................................................................... 1 Background ............................................................................................................................................ 1 Methods .................................................................................................................................................. 1 Key Findings .......................................................................................................................................... 3 Next Steps............................................................................................................................................... 4
1. Background ............................................................................................................................................ 6 1.1 National Context ............................................................................................................................ 6 1.2 The Nutritional Status of Women and Young Children in the Western Highlands of
Guatemala ...................................................................................................................................... 7 1.3 Optifood ......................................................................................................................................... 8 1.4 Characteristics of a Diet Associated with Good Child Growth and Development ........................ 9
2. Methods ................................................................................................................................................. 11 2.1 Step 1 – Collect Dietary and Food Cost Data: Methods of Cross-Sectional and Market Prices
Surveys for Information Gathering on Local Dietary Patterns and Food Costs ........................... 11 2.1.1 IRB Approval and Ethical Procedures ......................................................................... 11 2.1.2 Selection of Study Sites ............................................................................................... 11 2.1.3 Target Groups, Sample Size, and Participant Selection ............................................... 16 2.1.4 Training of Data Collectors ......................................................................................... 19 2.1.5 Data Collection Methods ............................................................................................. 19 2.1.6 Data Collection Tools .................................................................................................. 19 2.1.7 Recruitment Rates ........................................................................................................ 21 2.1.8 Data Quality ................................................................................................................. 21 2.1.9 Data Analysis ............................................................................................................... 22
2.2 Step 2 – Complete Analysis: Methods for Conducting Analysis Using Optifood ....................... 22 2.2.1 Data Entered into Optifood and Model Parameters ..................................................... 22 2.2.2 Data Analysis in Optifood ........................................................................................... 28
3. Results ................................................................................................................................................... 33 3.1 Results from the Cross-Sectional Survey and Information Gathering on Local Dietary
Patterns and Food Costs ............................................................................................................... 33 3.1.1 Background Characteristics ......................................................................................... 33 3.1.2 Household Hunger and Food Security ......................................................................... 34 3.1.3 Nutritional Status of Children 6–23 Months ................................................................ 36 3.1.4 Nutritional Status of Women ....................................................................................... 38 3.1.5 Infant and Young Child Feeding Practices .................................................................. 38 3.1.6 Most Frequently Reported Foods ................................................................................. 40 3.1.7 Main Food Sources of Nutrients .................................................................................. 40 3.1.8 Nutrient Intake and Adequacy ..................................................................................... 41 3.1.9 Protein Consumption ................................................................................................... 43
3.2 Results from Step 2: Analysis using Optifood ............................................................................. 44 3.2.1 Weekly Food Group Servings Needed to Optimize Nutritional Content of Diets ....... 44 3.2.2 Food Sources of Nutrients ........................................................................................... 46 3.3.3 Problem Nutrients ........................................................................................................ 51
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3.3.4 Food-Based Recommendations.................................................................................... 54 3.4.5 FBRs without Micronutrient Supplementation: ........................................................... 63 3.4.6 FBRs with Micronutrient Supplementation ................................................................. 63 3.4.7 Alternative Best Sets of FBRs ..................................................................................... 65 3.4.8 Analysis of Four Fortified Cereal Blends: Incaparina, Incaparina-Crecimax,
Vitacereal, and Corn-Soy Blend .................................................................................. 66 3.4.9 Cost Analysis ............................................................................................................... 67
4. Discussion .............................................................................................................................................. 70
5. Challenges in Using Optifood to Develop FBRs ................................................................................ 73
6. Next Steps ............................................................................................................................................. 74
References .................................................................................................................................................. 77
LIST OF APPENDICES
Appendix 1. Perceptions of Household Food Security ............................................................................... 81 Appendix 2. Foods Most Commonly Consumed by Children 6–23 Months .............................................. 82 Appendix 3. Foods Most Commonly Consumed by Pregnant Women and Lactating Women with
Infants under 6 Months ......................................................................................................................... 83 Appendix 4. Food Sources of Nutrients of Children 6–23 Months ............................................................ 84 Appendix 5. Food Sources of Nutrients of Pregnant Women and Lactating Women with Infants under
6 Months ............................................................................................................................................... 86 Appendix 6. Nutrient Intake from Complementary Foods of Breastfed Children 6–8 Months Old ........... 88 Appendix 7. Nutrient Intake from Complementary Foods of Breastfed Children 9–11 Months Old ......... 89 Appendix 8. Nutrient Intake from Complementary Foods of Breastfed Children 12–23 Months Old ....... 90 Appendix 9. Nutrient Intake of Non-Breastfed Children 12–23 Months Old ............................................. 91 Appendix 10. Nutrient Intake of Pregnant Women .................................................................................... 92 Appendix 11. Nutrient Intake of Lactating Women with Infants under 6 Months ..................................... 93 Appendix 12. Food Lists Entered into Optifood: Cost per 100 g of the Edible Portion, Median
Serving Sizes, Number of Consumers, and Maximum Number of Times per Week It Could Be
Consumed (Freq) by Target Group ...................................................................................................... 94 Appendix 13. The Food Group Constraints Used in the Models (servings/week) for Each Target
Group .................................................................................................................................................... 96 Appendix 14. The Food Subgroup Constraints Used in the Models (servings/week) for Each Target
Group .................................................................................................................................................... 97 Appendix 15. INCAP Recommended Dietary Allowances and Adequate Intakes (INCAP 2012) ............ 98 Appendix 16. Module 3, Stage 1: Formulation of FBRs for Breastfed Children 6–8 Months Old with
Incaparina and Fortified Instant Oats – Selection of the Key Messages .............................................. 99 Appendix 17. Module 3, Stage 1: Formulation of FBRs for Breastfed Children 9–11 Months Old
with Incaparina and Fortified Instant Oats – Selection of the Key Messages .................................... 101 Appendix 18. Module 3, Stage 1: Formulation of FBRs for Breastfed Children 12–23 Months Old
with Incaparina and Fortified Instant Oats – Selection of the Key Messages .................................... 103 Appendix 19. Module 3, Stage 1: Formulation of FBRs for Non-Breastfed Children 12–23 Months
Old with Incaparina and Fortified Instant Oats – Selection of the Key Messages ............................. 105 Appendix 20. Module 3, Stage 1: Formulation of FBRs for Pregnant Women with Incaparina and
Fortified Instant Oats and Liver – Selection of the Key Messages .................................................... 107
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Appendix 21. Module 3, Stage 1: Formulation of FBRs for Lactating Women with Incaparina and
Fortified Instant Oats – Selection of the Key Messages ..................................................................... 109 Appendix 22. Module 3, Stages 2–3: Formulation of FBRs for Breastfed Children 6–8 Months Old
with Incaparina and Fortified Instant Oats ......................................................................................... 110 Appendix 23. Module 3, Stages 2–3: Formulation of FBRs for Breastfed Children 9–11 Months Old
with Incaparina and Fortified Instant Oats ......................................................................................... 112 Appendix 24. Module 3, Stages 2–3: Formulation of FBRs for Breastfed Children 12–23 Months
Old with Incaparina and Fortified Instant Oats .................................................................................. 114 Appendix 25. Module 3, Stages 2–3: Formulation of FBRs for Non-Breastfed Children 12–23
Months Old with Incaparina and Fortified Instant Oats ..................................................................... 116 Appendix 26. Module 3, Stages 2–3: Formulation of FBRs for Pregnant Women with Incaparina
and Fortified Instant Oats and Liver ................................................................................................... 118 Appendix 27. Module 3, Stages 2–3: Formulation of FBRs for Lactating Women with Incaparina
and Fortified Instant Oats and Liver ................................................................................................... 120 Appendix 28. Food Composition Values: Incaparina, Incaparina-Crecimax, Vitacereal, CSB ............... 122 Appendix 29. Analysis of FBF for Breastfed Children 6–8 Months Old ................................................. 123 Appendix 30. Analysis of FBF for Breastfed Children 9–11 Months Old ............................................... 124 Appendix 31. Target Usual Intake Distribution of Iron for Breastfed Children 6–8 Months ................... 125 Appendix 32. Participant Selection Form for Pregnant and Lactating Women ........................................ 126 Appendix 33. Participant Selection Form for Children 6–23 Months of Age .......................................... 127 Appendix 34. Survey Form for Family Demographic, Health, Diet, Food Security, and Nutritional
Status of Women and Children ........................................................................................................... 128 Appendix 35. INCAP 24-Hour Dietary Recall Forms .............................................................................. 136 Appendix 36. Instructions for 24-Hour Dietary Recall (Spanish) ............................................................ 140 Appendix 37. Market Prices Survey Form ................................................................................................ 152
LIST OF TABLES
Table 1. Prevalence of Stunting and Anemia in the Western Highlands in Children 3–59 Months Old
(Stunting) and Children 6–59 Months Old (Anemia) ............................................................................. 7 Table 2. Essential Nutrients and Active Compounds and Their Dietary Sources ......................................... 9 Table 3. Communities Participating in Huehuetenango, by Municipality .................................................. 14 Table 4. Communities Participating in Quiché, by Municipality ............................................................... 15 Table 5. Sample Size of Breastfed Children 6–11 Months, by Department, Municipality, and
Program Participation (RVC or PEC) .................................................................................................. 17 Table 6. Sample Size of Children 12–23 Months, by Department, Municipality, and Program
Participation (RVC or PEC) ................................................................................................................. 17 Table 7. Sample Size of Pregnant Women, by Department, Municipality, and Program Participation
(RVC or PEC) ...................................................................................................................................... 18 Table 8. Sample Size of Lactating Women, by Department, Municipality, and Program Participation
(RVC or PEC) ...................................................................................................................................... 18 Table 9. Data Requirements for Optifood and the Sources of These Data ................................................. 23 Table 10. Sample Sizes of Target Groups by Department .......................................................................... 24 Table 11. Average Breast Milk Intake per Day Input in Optifood by Target Group .................................. 25 Table 12. Selected Socio-Demographic Characteristics of Households and Women Surveyed ................. 33 Table 13. Selected Characteristics of Children 6–23 Months, Pregnant Women, and Lactating
Women Surveyed ................................................................................................................................. 34
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Table 14. Household Hunger Scale............................................................................................................. 35 Table 15. Nutritional Status of Children 6–23 Months ............................................................................... 37 Table 16. Nutritional Status of Non-Pregnant Women (Including Lactating Women) .............................. 39 Table 17. Infant and Young Child Feeding Practices ................................................................................. 39 Table 18. Consumption of Processed Food with Low Nutritional Value by Children 6–23 Months
Old and Women .................................................................................................................................... 40 Table 19. Energy and Protein Intake from Complementary Food for Children 6–23 Months ................... 42 Table 20. Energy and Protein Intake for Pregnant and Lactating Women ................................................. 42 Table 21. Range in Food Group Patterns (servings/week) Selected for the Two Best Diets from
Module 2 and Modeled Food Group Pattern (individual servings/week) Goals .................................. 45 Table 22. Foods Providing > 5% of the Total Micronutrient Content of the Optifood Diet That Met or
Came as Close as Possible to Meeting Nutrient Needs ........................................................................ 47 Table 23. Top Three FOOD SUBGROUP Sources (excluding breast milk) in Ranked Order, of
Micronutrients and Fat in the Best Diet That Does Not Take Dietary Patterns into Account
(Diet B from Module 2) ........................................................................................................................ 49 Table 24. Top Three FOOD Sources (excluding breast milk) in Ranked Order of Fat and
Micronutrients in the Best Diet That Does Not Take Dietary Patterns into Account (Diet B from
Module 2) ............................................................................................................................................. 50 Table 25. Problem Nutrients ....................................................................................................................... 53 Table 26. FBRs and the Cost (GTQ/day) of the Lowest-Cost Diet That Includes the FBR(s) for
Children ................................................................................................................................................ 55 Table 27. FBRs and the Cost (GTQ/day) of the Lowest-Cost Diet That Includes the FBR(s) for
Pregnant and Lactating Women ........................................................................................................... 55 Table 28. Effect of Removing Individual Recommendations from the Set of FBRs for Each Target
Group .................................................................................................................................................... 56 Table 29. Problem Nutrients in Modeled Optifood Diets That Came as Close as Possible to Meeting
Nutrient Needs (from Module 3 results) .............................................................................................. 58 Table 30. FBRs without Including Micronutrient Supplementation for Children ...................................... 59 Table 31. FBRs without Micronutrient Supplementation for Pregnant and Lactating Women .................. 60 Table 32. FBRs including Micronutrient Supplementation for Children.................................................... 64 Table 33. FBRs with Micronutrient Supplementation for Pregnant and Lactating Women ....................... 65 Table 34. Lowest-Cost Nutritionally Best Dieta for Each Target Group .................................................... 68 Table 35. Food Selected for Lowest-Cost Nutritionally Best Diets for Each Target Group ...................... 69 Table 36. Prevalence of Micronutrient Deficiencies among Children 6–59 Months Old and
Women 15–49 Years Old, ENMICRON, 2009–2010 .......................................................................... 71
LIST OF FIGURES
Figure 1. The Four Modules of the Optifood Analysis ................................................................................. 3 Figure 2. Zero Hunger Plan: Key Actions .................................................................................................... 6 Figure 3. Process of Using Optifood to Develop and Promote FBRs ........................................................... 9 Figure 4. Criteria for the Selection of Municipalities ................................................................................. 12 Figure 5. Municipalities of Huehuetenango and Quiché Departments Included in the Study .................... 13 Figure 6. Average Iron and Zinc Densities of Children's Complementary Foods and Recommended
Densities ............................................................................................................................................... 43
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Abbreviations and Acronyms
AI adequate intake
BMI body mass index
CDC U.S. Centers for Disease Control and Prevention
cm centimeter(s)
CSB corn-soy blend
dL deciliter(s)
EAR estimated average requirement
ENMICRON Encuesta Nacional de Micronutrientes (National Survey of Micronutrients)
ENSMI Encuesta Nacional de Salud Materno Infantil (National Maternal-Infant Health Survey)
FANTA Food and Nutrition Technical Assistance III Project
FAO Food and Agriculture Organization of the United Nations
FBF fortified-blended flour
FBR food-based recommendation
FCT food composition table
FTF Feed the Future Initiative
FWA Federalwide Assurance
g gram(s)
GLV green leafy vegetable
GOG Government of Guatemala
GTQ Guatemalan quetzal
HFIAS Household Food Insecurity Access Scale
HHS Household Hunger Scale
INCAP Instituto de Nutrición de Centro América y Panamá (Institute of Nutrition of Central
America and Panama)
INE Instituto Nacional de Estadística (National Statistics Institute)
IOM Institute of Medicine
IYCF infant and young child feeding
iZiNCg International Zinc Nutrition Consultative Group
kcal kilocalorie(s)
LSHTM London School of Hygiene and Tropical Medicine
µg microgram(s)
mg milligram(s)
mL milliliter(s)
MNP micronutrient powder(s)
MPE meat, poultry, or eggs
MSPAS Ministerio de Salud Pública y Asistencia Social (Ministry of Public Health and Social
Assistance)
n.d. no date
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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NGO nongovernmental organization
OHRP Office for Human Research Protections
OPS Organización Panamericana de la Salud
PAHO Pan American Health Organization
PEC Programa de Extensión de Cobertura (Program for the Extension of Coverage)
PRDC Programa para la Reducción de la Desnutrición Crónica (Program for the Reduction of
Chronic Malnutrition)
RDA recommended dietary allowance
RNI recommended nutrient intake
RVC Rural Value Chain Project
SBCC social and behavior change communication
SD standard deviation(s)
SUN Scaling Up Nutrition
tbsp tablespoon(s)
TIPs Trials of Improved Practices
U.S. United States
UNU United Nations University
USAID U.S. Agency for International Development
USDA U.S. Department of Agriculture
WFP World Food Programme
WHO World Health Organization
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Executive Summary
Background
Nearly half of children under 5 in Guatemala are stunted, and anemia affects 29% of pregnant women,
21% of lactating women, and 48% of children under 5. Stunting and other indicators of poor nutrition are
even more pronounced in the Western Highlands region (Ministerio de Salud Pública y Asistencia Social
[MSPAS] [Ministry of Public Health and Social Assistance] 2010). This high level of chronic
malnutrition has severe consequences for the physical and cognitive development of affected children and
women, their families, communities, and the country overall (MSPAS/Instituto Nacional de Estadística
[INE]/U.S. Centers for Disease Control and Prevention [CDC] 2010; Black et al. 2013).
Poor nutritional status in the Western Highlands has been attributed to suboptimal infant and young child
feeding (IYCF) practices, low dietary diversity, food insecurity, and poor access to health services
(Chaparro 2012; De Pee and Bloem 2009). As part of the United States Government’s Feed the Future
Initiative3 (FTF), the U.S. Agency for International Development (USAID) is supporting the Government
of Guatemala (GOG) to implement the Plan of the Zero Hunger Pact,4 through integrated health, nutrition,
agriculture, and local governance projects in the Western Highlands.
To support implementation of the Zero Hunger Plan, USAID/Guatemala requested assistance from
FHI 360’s Food and Nutrition Technical Assistance III Project (FANTA) to identify strategies to improve
the nutritional quality of the diet in the Western Highlands for pregnant and lactating women and children
6–23 months of age based on locally available foods. In partnership with the Instituto de Nutrición de
Centro América y Panamá (INCAP) (Institute of Nutrition of Central America and Panama) and the
London School of Hygiene and Tropical Medicine (LSHTM), FANTA initiated an activity to use a
computer program called Optifood to identify a set of evidence-based, population-specific, food-based
recommendations (FBRs) for these target populations.
Optifood analyzes the actual dietary patterns of target groups and the costs of local foods to identify the
lowest-cost combination of local foods that will meet or come as close as possible to meeting the nutrient
needs of specific groups. Optifood can also be used to identify “problem nutrients” (dietary requirements
that would be difficult to meet using diets based on locally available foods), analyze diet costs, and
compare and test different FBRs or interventions.
Methods
To establish the dietary patterns of the target groups, data were collected using a cross-sectional survey of
randomly selected children 6–11 months old (n=202) and children 12–23 months old (n=190), pregnant
women (n=75), and lactating women (n=80), across 40 rural communities in the departments of
Huehuetenango and Quiché between July and September 2012. The data collection process included:
1. A household survey to collect socioeconomic, demographic, and health information
2. The Household Food Insecurity Access Scale (HFIAS) (Coates et al. 2007) to determine the
level of food insecurity experienced in study communities
3 http://www.feedthefuture.gov/. 4 http://www.sesan.gob.gt/index.php/descargas/17-plan-del-pacto-hambre-cero.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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3. A 24-hour dietary recall tool to collect information on foods commonly consumed by the target
populations, serving sizes, and consumption patterns
4. An anthropometric survey of study participants for determining nutritional status and for
calculating energy and protein requirements of the population
5. A market prices survey instrument based on the ProPAN methodology5 to collect data on the
local names for foods, local costs, seasonality, and availability of food
The study was carried out during the rainy season. Despite the fact that this time of the year is also called
the lean or hungry season (because families are between maize harvests and there is little paid agricultural
labor available to provide income for food purchases) (Mazariegos and Méndez 2013), many native green
leafy vegetables and fruits are more readily available during the rainy season, because they are either
produced in home gardens or purchased in the market. This study did not address the issue of seasonality;
however, the impact of seasonality on the feasibility of putting FBRs into practice will be explored in
subsequent household trials of the FBRs.
Figure 1 describes the data used by Optifood to set the model parameters and the four modules of data
analysis. Data used to develop realistic FBRs include actual dietary patterns and portions consumed by
the target population, reference values for recommended dietary allowances (RDAs), and costs of foods
consumed by the target population. The first Optifood analysis module checks that these model
parameters are realistic. The second module identifies the diet that would meet or come as close as
possible to meeting nutrient needs, within the model parameters, as well as the best possible diet
regardless of these parameters. This module is also used to identify problem nutrients and food sources of
problem nutrients, for drafting FBRs. The third module is used to test and compare alternative FBRs,
taking into consideration current practices, nutrient needs, and cost, if cost is included in the analysis.
Last, a cost analysis is conducted (Module 4) to identify the lowest-cost diet that meets or comes as close
as possible to meeting nutrient needs.
5 See ProPAN Module 1. http://www.paho.org/common/Display.asp?Lang=E&RecID=6048. This manual, aimed at ministries of
health, NGOs, organizations, and bilateral and international organizations interested in improving IYCF practices to prevent early
childhood malnutrition, describes how to design an intervention and reviews evaluation strategies. At the time of the study, the
ProPAN modules were being updated so that they could easily be used with Optifood. The ProPAN tools used in this activity were draft updated versions.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Figure 1. The Four Modules of the Optifood Analysis
Key Findings
The women and children surveyed came from predominantly rural, indigenous households characterized
by a high prevalence of stunting and anemia, from Western Highlands departments that have been
prioritized for nutrition interventions. Roughly half of households experienced anxiety or concern
regarding food security in the 30 days preceding the survey, although few households reported
experiencing hunger due to lack of food, according to the subset of questions focused on these criteria.
The largest problems identified in the diets of the women and children surveyed related to diet quality, not
quantity. Observed diets in all target groups were largely plant based, with few animal-source foods or
fortified foods. This was disadvantageous, given the relatively high content of antinutrients that impede
the uptake of other nutrients, the lower bioavailability of certain micronutrients, and the lack of specific
nutrients and active compounds contained in animal-source foods (De Pee and Bloem 2009). Further,
given that animal protein was consumed by all target groups only in small amounts and that grains and
legumes were not often consumed together, it is possible that protein levels in the population are
inadequate.
The Optifood analysis revealed that zinc, iron, vitamin B12, and folate were problem nutrients. Further,
iron and zinc nutrient requirements for children 6–8 months old and iron requirements for pregnant
women could not be met using diets based on local foods.
The Optifood results suggested that a combination of six FBRs that include fortified-blended flour (FBF)
for children 6–23 months old and a similar set of six FBRs that include FBF for pregnant and lactating
women could ensure that dietary adequacy is met for all target groups, except for the requirements of iron
and zinc for children 6–8 months old and iron for pregnant women. Nutrient adequacy for children 6–8
months old and pregnant women was not possible without micronutrient supplementation. While nutrient
adequacy could be met using a combination of FBRs for all other target groups, the quantity of local food
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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required to put these FBRs into practice was high and the recommendations may not be feasible or
acceptable for target communities given the cost of implementation, the gastric capacity of individuals,
and dietary preferences. Therefore, it is suggested that a more conservative set of 4–7 FBRs be
recommended for each target group, in combination with appropriate micronutrient supplementation.6,7,8
Even given the adjustments to the modeled diets once micronutrient supplementation was considered, it
was concluded that nutritionally adequate diets might not be affordable or accessible for some households
in the Western Highlands. Other constraints may also prevent families from implementing the final sets of
FBRs. It is therefore recommended that potential constraints, such as cost, access to foods, seasonality of
production, time required to prepare food, and cultural beliefs regarding recommended foods, should be
further explored to test the feasibility, availability, and acceptability of putting the FBRs in place and to
develop effective strategies for supporting a nutritionally adequate diet for the most vulnerable groups.
Next Steps
Further activities are required to investigate the feasibility and acceptability of promoting the FBRs for
the target populations. Additionally, while there is a need to promote the FBRs through dietary changes,
there is also a need to promote complementary strategies to increase the nutrient intake for women and
children, taking into consideration local availability, production, and costs of foods. Thus, the next step in
this process is a review of the results of this project by USAID/Guatemala, the GOG, and partners to
develop an integrated plan for the improvement of women’s and children’s nutrient intake in the Western
Highlands, considering the most promising programmatic options, which may include promotion of FBRs
through behavior change, promotion of agriculture or animal husbandry, food fortification, supplementa-
tion with micronutrients, or other approaches. The following issues should be considered in this process:
1. The use of findings to develop messages for a social and behavior change strategy and
program activities by the GOG with the support of cooperating agencies (including the Nutri-
Salud project9)
2. The role of agricultural interventions in increasing home production and market availability of
important food sources for problem nutrients, including black beans, animal-source foods, green
leafy vegetables (GLVs), and factors influencing home/local production
3. Food fortification and micronutrient supplementation policies, including an analysis of the
complementarity (or redundancy) of current GOG micronutrient policies, their effectiveness to
meet desired objectives (e.g., prevent anemia, promote linear growth), recommended
modifications, and their relationship to the findings presented in this report
4. Complementary foods that would provide adequate iron and zinc densities for young children
and further analysis to evaluate the need for and the effectiveness and feasibility of
complementary food supplements
5. Feasibility and affordability of FBRs: Planned trials during 2014 will identify individual FBRs
that are feasible for families to implement, as well as barriers and potential motivating factors to
6 The World Health Organization (WHO) recommended a duration and time interval for supplementation with multiple
micronutrient powders (MNP) for children 6–23 months old of one sachet per day for a minimum period of 2 months, followed by a period of 3–4 months off supplementation so that use of a multiple MNP is started every 6 months. 7 The composition of the Sprinkles include: 12.5 mg of iron, 300 µg of retinol, 5 mg of zinc, 160 µg of folic acid, and 30 mg of vitamin C. 8 Recommended supplementation for pregnant and lactating women includes 600 mg/week of ferrous sulfate and 5 mg/week of folic acid (MSPAS 2004). 9 The Nutri-Salud Community Nutrition and Health Project, administered by University Research Co. LLC, is a USAID-funded
project that operates in 30 municipalities in 5 departments of the Western Highlands of Guatemala to support the Guatemalan
Ministry of Health’s efforts to expand health coverage at the community level. Information is available at http://www.urc-chs.com/project?ProjectID=243.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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help encourage their adoption; the final outcomes from the trials will be a realistic set of evidence-
based, population-specific FBRs, and the content for messages to promote them in the Western
Highlands
6. Strengthening agricultural/nutrition linkages through collaboration with the Ministry of
Agriculture and Livestock and MSPAS to develop extension programs that support the production
of nutrient-dense foods and to develop social and behavior change communication (SBCC)
messages that help consumers optimally integrate those foods in their diets
7. Applicability of the FBRs to other areas of the Western Highlands: Studies are needed to
determine the extent to which the FBRs are applicable to other areas within the Western Highlands
8. Involving the private sector to develop and field test complementary foods products that would
address identified nutrient inadequacies
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1. Background
1.1 National Context
Guatemala has the highest percent of children suffering from chronic malnutrition in the Western
Hemisphere (USAID 2012). Almost 50% of children under 5 years of age are stunted, that is, too short for
their age (Black et al. 2013; MSPAS/INE/CDC 2010). The GOG, through its Zero Hunger Plan, aims to
dramatically reduce chronic malnutrition among children under 5 years, with a goal of a 10% reduction
by 2015 and a 24% reduction by 2022 (GOG n.d.). The Zero Hunger Plan is based on the national
Programa para la Reducción de la Desnutrición Crónica (PRDC) (Program for the Reduction of Chronic
Malnutrition) and the international Scaling Up Nutrition (SUN) Movement.10 The actions of the Zero
Hunger Plan are focused on the 1,000 days from pregnancy through a child’s second birthday, “the 1,000-
day window,” when the most-rapid physical growth of the child occurs and a critical time in cognitive
development. The Zero Hunger Plan includes 10 key actions to prevent chronic malnutrition and 5 key
actions to prevent seasonal hunger (Figure 2).
Figure 2. Zero Hunger Plan: Key Actions
10 key actions to prevent chronic malnutrition in Guatemala
1. Promotion and support of breastfeeding 2. Improvement in complementary nutrition after 6 months of age 3. Improvement in hygiene practices, including washing of hands 4. Provision of vitamin A supplements (for children 6–23 months old) 5. Provision of therapeutic zinc supplements in cases of diarrhea 6. Provision of powdered micronutrients (for children 6–23 months old) 7. Deworming and vaccination campaigns for boys and girls 8. Provision of iron and folic acid supplements for the prevention and/or treatment of anemia in pregnant
women 9. Prevention of iodine deficiency through iodized salt 10. Provision of food products fortified with micronutrients
5 key actions to prevent seasonal hunger
1. Support of family agriculture to increase production for self-consumption and sale, with proper techniques and few inputs
2. Prevention and treatment of moderate acute malnutrition at the community level by providing ready-to-use foods
3. Treatment of acute malnutrition in a timely fashion using ready-to-use therapeutic food at the community level and in nutritional recovery centers, with guidance and follow-up provided by health care practitioners
4. Establishment of a food and nutrition surveillance alert system based on nutritional surveillance networks that include sentinel sites
5. Social protection network against seasonal hunger through a temporary work program (intensive hand labor) and conditional monetary transfers and humanitarian assistance
Source: GOG. n.d.
As part of FTF and GHI, USAID is supporting the GOG to implement the Zero Hunger Plan through
integrated health, nutrition, agriculture, and local governance projects in the Western Highlands. This
support is specifically focused on the departments of Huehuetenango, Quetzaltenango, Quiché, San
Marcos, and Totonicapán.
10 See http://scalingupnutrition.org/.
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To complement the Zero Hunger Plan, USAID/Guatemala requested assistance from FANTA to identify
strategies to improve the nutritional quality of the diet in the Western Highlands for pregnant and
lactating women and children 6–23 months of age based on locally available foods. In 2012, in
partnership with INCAP, FANTA initiated an activity to use Optifood, a computer program, to identify a
set of evidence-based, population-specific FBRs that can be promoted to improve the nutritional status of
women and young children in the Western Highlands.11
1.2 The Nutritional Status of Women and Young Children in the Western Highlands of
Guatemala
Chronic malnutrition is rampant in the Western Highlands (Table 1) (MSPAS/INE/CDC 2010).
According to the 2008–09 Encuesta Nacional de Salud Materno Infantil (ENSMI) (National Maternal-
Infant Health Survey), four of the five departments in the Western Highlands have stunting prevalence
among children 3–59 months old greater than the national average, and three of the five departments—
Huehuetenango, Quiché, and Totonicapán—are among the four departments with the highest prevalence
of stunting in the country.12 Anemia is also pervasive: Nationally, 48% of children 6–59 months old are
anemic, and the prevalence of anemia in the Western Highlands ranges from 40% in Quetzaltenango to
62% in Totonicapán. Nationally, 20.6% of pregnant women and 35.5% of non-pregnant women between
15 and 19 years old are anemic, with rates between 20.6% (Quetzaltenango) and 32.3% (Totonicapán) for
non-pregnant women and 17.9% (Huehuetenango) and 36.3% (Totonicapán) for pregnant women in the
Western Highlands. More than half of all women with children aged under 5 years (50.5%) in the
Western Highlands are less than 145 cm tall, compared to 31.2% nationally, with prevalence ranging from
33% in San Marcos to 53.9% in Quiché.
Table 1. Prevalence of Stunting and Anemia in the Western Highlands in Children 3–59 Months Old (Stunting) and Children 6–59 Months Old (Anemia)
Hu
ehu
eten
ango
Qu
etza
lten
ango
Qu
ich
é
San
Mar
cos
Toto
nic
apán
Nat
ion
al
Prevalence (%) of stunting 69.5 43.1 72.2 53.5 82.2 49.8
Prevalence (%) of anemia 47.7 40.2 47.4 52.6 62.2 47.7
Source: MSPAS/INE/CDC. 2010.
11 Note that FBRs may not constitute the entire diet, but are intended to be put into practice as part of the usual diet of locally
available foods for the target group. The “usual” diet is based on preference, food frequency, and cost data. Some FBRs are not
tested or promoted if they are already put into practice by the population as part of a normal diet. For example, the majority of the
population surveyed in 2012 was already following the FBR of “Eat tortillas or tamalitos 3 times a day, 7 days a week.” The final
set of FBRs that are tested include messages that would constitute a change in dietary practices that would help improve nutrient
intake, to be practiced along with consumption of other nutritious, commonly consumed foods. Also note that Optifood does not include recommendations to not eat a particular food.
12 Stunting is defined as height-for-age < −2 standard deviations (SD) from the median of the 2006 WHO Child Growth Standards. See http://www.who.int/childgrowth/en/.
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1.3 Optifood
Optifood was developed by the World Health Organization (WHO) in collaboration with LSHTM;
FANTA; and Blue-Infinity, an information technology company. Optifood analyzes the actual dietary
patterns of target groups and food costs to identify the lowest-cost combination of local foods that will
meet or come as close as possible to meeting nutrient needs of specific target groups.13
Analysis in Optifood provides the following categories of results:
1. Best food sources. Based on locally available foods and dietary patterns, Optifood determines
which local foods are good sources of nutrients for a given target group.
2. Problem nutrients. Problem nutrients refer to nutrients that are likely to remain low in diets
given local food sources and existing dietary patterns. As well as identifying problem nutrients,
Optifood analysis indicates whether inadequate dietary intakes are related to the food selection
practices of a target group or to inadequate availability in the area or access to nutrient-dense
foods in the household. This information helps elucidate the strategies required to improve dietary
intake. When inadequate dietary intakes are related to food selection, a focus on behavior change
is needed; when they are related to inadequate availability or access to appropriate foods, a focus
on alternative strategies (e.g., supplementation, agricultural, and/or income generation
interventions) in addition to behavior change is required.
3. FBRs. Based on the best food sources and taking into account the problem nutrients for each
target group, alternative sets of FBRs are tested by Optifood using linear programming and
compared based on nutrient adequacy and cost. Through this process, Optifood can develop a set
of FBRs that ensures, or comes as close as possible to ensuring, a nutritionally optimal diet for
individuals in the target group.
4. Lowest-cost diet that meets or comes as close as possible to meeting nutrient needs. The
lowest-cost diet that meets or comes as close as possible to meeting nutrient needs is a diet in
which the Optifood program uses cost data to minimize cost while meeting or coming as close as
possible to meeting nutrient needs in the diet. This result provides information about the
affordability of this diet for specific target groups in the study area.14
Thirteen key nutrients are considered by the Optifood analysis: total fat, total protein, iron, zinc, calcium,
vitamin A, vitamin C, thiamin, riboflavin, niacin, vitamin B6, folate, and vitamin B12. Some important
nutrients in the diet cannot yet be analyzed in Optifood due to a lack of adequate food composition table
(FCT) data or because exact requirements have not yet been established. These include selenium, iodine,
biotin, vitamins K and D, essential fatty acids, and protein quality.
The process of using Optifood to develop FBRs has five main steps (Figure 3). This report describes
methods and results of Optifood to collect data on local dietary patterns and food costs (Step 1) and the
analysis in Optifood (Step 2) for children 6–23 months old, pregnant women, and lactating women with
infants under 6 months to develop the FBRs that were presented to and discussed with relevant
stakeholders. The report also discusses considerations for the next steps (Step 3 and 4), during which the
feasibility and acceptability of the FBRs will be tested in household trials and the GOG, USAID/
Guatemala, and partners will review the results of the Optifood analysis to decide on a final set of FBRs.
13 “Dietary pattern” is defined by the locally available foods that are most commonly consumed by the target group, the quantities
of these foods most commonly consumed by the target group, and the frequency of consumption of these foods by the target group during a 1-week period. 14 Cost data for Optifood can be collected through a market prices survey in the target area. A market prices survey tool is
available in the ProPAN toolkit, which can be found at: http://www.paho.org/hq/index.php?option=com_content&view=article&id=5668&Itemid=4067.
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Step 5—development and implementation of an SBCC strategy—will be conducted by Nutri-Salud after
Steps 3 and 4 have been completed.
Figure 3. Process of Using Optifood to Develop and Promote FBRs
1.4 Characteristics of a Diet Associated with Good Child Growth and Development
Table 2 (adapted from an article by de Pee and Bloem [2009]) shows the nutrient groups and active
compounds that are vital for good child growth and development, together with their main dietary
sources. In summary, the diets of young children should have a high micronutrient content, high energy
density, adequate protein content and quality, low antinutrient content, and adequate fat content and
quality.
Table 2. Essential Nutrients and Active Compounds and Their Dietary Sources
Nutrients and active compounds of concern Dietary sources Comments
Vitamins, plant origin
Vegetables and fruits, grains
Bioavailability (due to antinutrient content of plant foods) as well as absolute quantity of foods to be consumed is of concern.
Minerals Animal-source foods and plant foods
When largely relying on plant foods, intake has to be high and bioavailability has to be improved, particularly by reducing contents of antinutrients and/or adding vitamin C.
Vitamins, animal origin
Breast milk, animal milk, organ meat, red meat, poultry, fish, eggs
A variety of animal-source foods is required.
Iodine Seafood and iodized salt
The use of iodized salt contributes greatly to the prevention of iodine-deficiency disorders.
Proteins Soybeans, peanuts, legumes, breast milk, animal milk, organ meat, red meat, poultry, fish, eggs
Similar to vitamins from animal-source foods, a variety of foods is required to ensure adequate intake (AI) of all essential amino acids. Plant sources of protein also have a relatively high content of antinutrients, which affects absorption of minerals.
Essential fatty acids
Fatty fish or their products, soybean oil, rapeseed (canola) oil
Only fatty fish and a few oils have a favorable fatty acid profile, and these are not generally consumed in large amounts in most developing-country diets, including Guatemala (Menchú and Méndez 2011).
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Nutrients and active compounds of concern Dietary sources Comments
Growth factor from milk*
Dairy products (breast milk, animal milk, yogurt, cheese)
Skimmed-milk powder when reconstituted with water is not appropriate for young children because of the lack of fat. Full-cream milk powder is usually skimmed-milk powder to which powdered vegetable fat has been added. When reconstituted with clean, safe water, this is good milk for children.
Phytase, α-amylase (antinutrients)
Present in grains themselves, released when germinating, malting, or fermenting
These processes require modification of food processing as well as use of whole grains rather than purchased flour. Also, the impact of these food-processing technologies on improving mineral bioavailability and micronutrient status has not been shown to be substantial enough to markedly reduce deficiencies.
* The presence of factors in milk (peptides or non-phytate-bound phosphorus) that promote growth is very likely but not fully
proven as yet.
WHO has established guidelines with respect to the nutrient content of complementary foods for children
6–23 months of age (Pan American Health Organization [PAHO] and WHO 2004; WHO 2005). These
guidelines include a recommendation that meat, poultry, fish, or eggs should be eaten daily, or as often as
possible, because they are rich sources of many key nutrients. Diets that do not contain animal-source
foods cannot meet all nutrient needs at this age unless fortified products or nutrient supplements are used,
especially for children between 6 and 23 months of age that are not breastfed. In addition, if milk and
other animal-source foods are not eaten in adequate amounts, both grains and legumes should be
consumed daily, if possible within the same meal, to ensure adequate protein quality. The
complementarity of grains and legumes is related to the amino-acid content of each component. In an
example relevant to the Guatemalan context, the protein contained in maize is deficient in lysine and
tryptophan but rich in sulfur-containing amino acids (methionine and cystine), while the protein contained
in legumes, such as black beans, is rich in lysine and tryptophan but low in sulfur amino acids (Bressani
and Elías 1974). As such, it is recommended that beans and maize be consumed together where possible,
in a ratio of 30 parts beans to 70 parts maize (Food and Agriculture Organization of the United Nations
[FAO] 1993).
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2. Methods
2.1 Step 1 – Collect Dietary and Food Cost Data: Methods of Cross-Sectional and
Market Prices Surveys for Information Gathering on Local Dietary Patterns and
Food Costs
2.1.1 IRB Approval and Ethical Procedures
The study protocol was approved by the INCAP Institutional Ethics Review Committee, which is
registered with the Office for Human Research Protections (OHRP) at the United States Department of
Health and Human Services, through the Federalwide Assurance (FWA) for the Protection of Human
Subjects for International (Non-U.S.) Institutions15 and with the Institutional Review Board Information.16
The protocol approval was issued in July 2012, prior to beginning any contact with potential families.
Ethical approval for the analyses of the data collected by INCAP was obtained from LSHTM’s Ethics
Committee in November 2012.
The local leaders of the communities where the data collection took place were informed of the project,
the procedures to be undertaken, and how the data would be used. Relevant staff from the health services
and from the MSPAS Programa de Extensión de Cobertura (PEC) (Program for the Extension of
Coverage) were contacted and informed of the study prior to the recruitment. Fieldworkers carried an
identification card and a letter explaining their presence in the community when they were recruiting
participants and collecting data.
When a fieldworker identified an eligible participant, she or he explained the rationale, procedures, time
commitment, risks, and benefits of the study to the potential participant (or the mother/caregiver, in the
case of a child), and asked permission, both verbally and in writing, to interview the eligible participant.
If the pregnant or lactating woman or the mother/caregiver of the child consented, the participant signed
the informed consent form with either her signature or a thumbprint. For illiterate or non-Spanish-
speaking women, the informed consent was read or translated into the local language. INCAP hired local
fieldworkers who supported the field team as guides and translators, facilitating the translation needs
during the informed consent process and the interviews. For a participant who could not sign her name, in
addition to the participant providing her thumbprint, a local witness also signed the consent form.
As part of the benefits, the study provided nutrition counseling to all participating mothers, geared toward
improving feeding practices of the child, and to pregnant and lactating women, that included the topics of
breastfeeding, complementary feeding, and handwashing. The counseling sessions took place right after
completing the survey interview. In addition, mothers of children received free of charge a plastic dish
and a cup for child feeding used to promote good feeding practices.
2.1.2 Selection of Study Sites
Selection of Departments
As mentioned earlier, the goal of this study was to identify population-specific FBRs that can be
promoted to improve the nutritional status of women and young children in the Western Highlands. To
carry out the studies, FANTA and INCAP focused on nine municipalities in the Highlands (four
municipalities in the department of Huehuetenango, which is populated predominantly by the Mam
15 Through the FWA, an institution commits to the Department of Health and Human Services that it will comply with the
requirements in the Protection of Human Subjects regulations at 45 CFR Part 46. INCAP’s identification number is 00000742. 16 Identification numbers IORG0006269 and IRB000075.
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ethnolinguistic group and five municipalities in the department of Quiché populated predominantly by the
Ixil and Quiché ethnolinguistic groups). Conducting the study in two different locations allowed for a
greater range of diet patterns and for evaluation of the applicability of the FBRs for both departments.
These two departments were purposively selected based on regional priorities of the GOG Zero Hunger
Plan and USAID/Guatemala. Study departments were selected from USAID FTF and GHI areas of
intervention, including the USAID-funded FTF Rural Value Chain Project (RVC) and PEC.
The RVC is led by a consortium of Guatemalan nongovernmental organizations (NGOs) including
Agexport, INCAP, and Vital Voices (collectively known as the Consorcio Unidos por el Desarrollo
Rural [United Consortium for Rural Development]). The RVC works through local farmers’ associations
and aims to improve nutrition and food security by promoting economic growth through support of
horticulture and coffee production. The rationale for selecting RVC participants was that they may have
greater dietary diversity due to the agricultural activities in which they are engaged and, therefore,
represent a broad range of dietary patterns in the area.
Under PEC, MSPAS NGOs are contracted to provide health services to rural areas where the government
health system does not have adequate coverage. The respondents from PEC were selected from the same
municipalities as the RVC participants. The rationale for selecting participants from PEC is that families
receiving PEC services represent the majority of the population in these communities. In addition, they
are often the poorest and most vulnerable, and subsequently at high risk of chronic malnutrition. The
dietary patterns of PEC participants also could be different than those of RVC participants who may have
more resources (e.g., land and income).
Selection of Municipalities
Municipalities within departments were purposively selected considering their ecological and geographic
zones so that current agricultural production and dietary practices would be similar across contiguous
priority municipalities, to ensure geography-specific FBRs that would be generalizable across the
geographically targeted areas.
Figure 4. Criteria for the Selection of Municipalities
Municipality Selection Criteria
1. Similar ecological zone within department 2. Similar geographic zone within department 3. Participation in PEC project 4. Participation in RVC project
Quiché has a total of 21 municipalities; 5 of these were selected for data collection, including 4 in the
“Quiché region” of the department—Cunén (Ki’che language), Nebaj and Chajul (Ixil language group),
and Sacapulas (Sacaputecol language group)—and one in the Ixil region of the department—San Juan
Cotzal (Ixil language group).
At the time of the survey, the RVC project was present in eight municipalities in the Quiché department,
four of which (Cunén, Nebaj, Chajul, and Sacapulas) were selected for the study. San Juan Cotzal
municipality was not supported by RVC at the time of the survey, but since the survey it has been added
to the RVC project. San Juan Cotzal has similar characteristics to those in the Quiché region and was
selected for the survey because of the interest and support received by the health authorities. The five
municipalities surveyed in Quiché had PEC presence.
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Four municipalities were selected in the Mam ethnolinguistic group areas in the department of
Huehuetenango: San Sebastián Huehuetenango, San Pedro Nécta, Chiantla, and Todos Santos
Cuchumatán. Huehuetenango has 31 municipalities, of which 8 were participating in the RVC project.
The four survey municipalities in Huehuetenango had PEC and RVC presence, as shown in Table 3 (on
the next page).
Figure 5 shows the five departments where the USAID FTF is being implemented by Consorcio Unidos
por el Desarrollo Rural and the nine municipalities where the study was carried out.
Figure 5. Municipalities of Huehuetenango and Quiché Departments Included in the Study
Selection of Communities
Study communities were purposively selected based on the presence of families participating in the RVC
project and/or the presence of PEC. Selection of communities was also based on verbal support for the
survey obtained by governors from Huehuetenango and Quiché and leaders of the associations
participating in the RVCs, as well as written authorization from the directors of the Health Areas and
Health Municipal Districts who are responsible for the PEC.
Twenty communities each were selected from Quiché and Huehuetenango departments. Originally in the
sampling design, each municipality was considered a stratum that consisted of a set number of
communities, with each community contributing equally to the overall study sample size. However, due
to difficulties in locating households with young children or pregnant women, it was necessary to allow
differentiation in the number of communities in the strata by adding additional communities to some of
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them. For example, when it was not possible to locate enough young children and pregnant women in a
selected community, a neighboring community was included in the stratum so that the required sample
size could be met. Table 3 and Table 4 present the final list communities surveyed in each municipality.
Table 3. Communities Participating in Huehuetenango, by Municipality
Municipality Community Name Type of Population Center* RVC (name)
or PEC Presence Community**
San Sebastián Huehuetenango
Piol Village PEC presence
Sipal Caserío PEC presence
Quiajola Village PEC presence
Chelam Caserío PEC presence and RVC (ASOSAM)
Chiantla
Buena Vista Caserío PEC presence
Chochal Village PEC presence and RVC (ADICHO)
La Esperanza Caserío PEC presence
Cuatro Caminos Without information PEC presence
San Pedro Nécta
El Llano Without information PEC presence
Chimiche Village PEC presence and RVC
(ACODIHUE)
El Rancho Without information PEC presence
La Pinada Caserío PEC presence and RVC
(ACODIHUE)
Guachipilin Caserío PEC presence
Todos Santos Cuchumatán
San Martín Village PEC presence and RVC (ADAT)
Los Lucas Caserío PEC presence and RVC (ADAT)
Chiabal Caserío PEC presence
Chicoy Village PEC presence
Tujchoj Without information PEC presence
Tuiich Without information PEC presence
Los Gómez Caserío PEC presence
Total 20
* INE toponymy: A caserío is a rural hamlet with fewer than 500 inhabitants.
** The purpose of distinguishing between PEC and RVC was for the first source of identification and recruitment of participants.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Table 4. Communities Participating in Quiché, by Municipality
Municipality Community Name Type of Population Center* RVC (name)
or PEC presence in community**
Nebaj
Turanza Caserío PEC presence
Acul Village PEC presence
Río Azul Caserío PEC presence
Bisán Caserío PEC presence
Pexlá Village PEC presence and RVC (ASIES)
Xeucalvitz Caserío PEC presence and RVC (Agros.
Café Ixil)
Chajul
Juil Caserío PEC presence
Xolcuay Village PEC presence and RVC (APRODEFI)
Xix Village PEC presence and RVC (APRODEFI)
Chacalté Village PEC presence
Chajul Township PEC presence and RVC (ASIES)
San Juan Cotzal
Cajixay Village PEC presence
Villa Hortencia A. Village PEC presence
Pinal Village PEC presence
Buenos Aires Village PEC presence
Cunén El Pericón Village PEC presence and RVC (AIDA)
Tierra Colorada Caserío PEC presence and RVC (ACODE)
Sacapulas
Río Blanco Village PEC presence and RVC
(PROGRESAR)
Rancho de Teja Village PEC presence
La Abundancia Farm PEC presence
Total 20
* INE toponymy: A caserío is a rural hamlet with fewer than 500 inhabitants.
** The purpose of distinguishing between PEC and RVC was for the first source of identification and recruitment of participants
Process for Informing Departmental, Municipal, and Community Stakeholders
The study was presented to the directors of the Departmental Health Areas, Departmental Governors, and
appropriate leadership teams of the NGOs running PEC services in the study communities. With the
approval and support of these key stakeholders, local leaders from the communities in which the data
collection took place were informed of the study, its procedures, and how the data were going to be used.
Local staff from the RVC and PEC were also informed about the study prior to the start of participant
recruitment.
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2.1.3 Target Groups, Sample Size, and Participant Selection
Target Groups for Sampling
Data for the survey were collected for the following target groups:
1. Children 6–11 months of age
2. Children 12–23 months of age
3. Pregnant women
4. Lactating women with children under 6 months of age
Sample Sizes
Sample sizes for the collection of household and dietary data from the target groups were based on
sample sizes previously reported in the literature that used Optifood’s linear programming techniques
(Santika et al. 2009) and recommendations provided by researchers experienced with Optifood (Ferguson
2012) as to how many replicates were assumed to be sufficient to capture the potential variability in
dietary patterns. Based on these sources of information, the proposed sample size for the study included:
200 children 6–11 months of age
200 children 12–23 months
75 pregnant women
75 lactating women with infants under 6 months
The intention was that the overall sample size would be split equally among the departments of
Huehuetenango and Quiché. Table 5 through Table 8 shows the actual sample sizes by target group.
Local Support for Participant Recruitment
Local representatives from the RVC and PEC guided the survey team through the community and
introduced them to the selected families. Fieldworkers carried identification and a letter of presentation
explaining their presence in the community when recruiting respondents and collecting data. Local
community members associated with the RVC and PEC translated Mam, Ixil, and Quiché for
fieldworkers when respondents did not speak Spanish.
Selection of Participants
In each community, potential survey participants were randomly selected from either the RVC list in
RVC communities or the PEC list from the PEC clinic in PEC communities. In some communities, when
there were no more eligible RVC participants, the PEC list was used to complete the selection of potential
participants. The number of eligible families participating in the rural value chains was usually small and,
therefore, its contribution to the overall sample size was lower with respect to the PEC.
If a selected participant (pregnant or lactating woman or mother of a child 6–23 months old) was not
available in her home, a repeat visit was conducted later in the day. However, if the participant was not
available by the end of the day, a replacement was selected from a list of available replacements.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Table 5. Sample Size of Breastfed Children 6–11 Months, by Department, Municipality, and Program Participation (RVC or PEC)
Department Municipality
Number of participants from RVC communities
Number of participants from communities with
PEC presence Total
Huehuetenango Chiantla 8 20 28
San Pedro Nécta 4 27 31
San Sebastián Huehuetenango 2 16 18
Todos Santos Cuchumatán 2 22 24
Total number 16 85 101
Total percentage 16 84 100
Quiché Nebaj 3 25 28
Chajul 5 17 22
Cotzal 0 24 24
Sacapulas 5 18 23
Cunén 4 0 4
Total number 17 84 101
Total percentage 17 83 100
Total Total number 33 169 202
Total percentage 16 84 100
Table 6. Sample Size of Children 12–23 Months, by Department, Municipality, and Program Participation (RVC or PEC)
Department Municipality
Number of participants from RVC communities
Number of participants from communities with
PEC presence Total
Huehuetenango Chiantla 8 13 21
San Pedro Nécta 6 20 26
San Sebastián Huehuetenango 1 22 23
Todos Santos Cuchumatán 6 22 28
Total number 21 77 98
Total percentage 22 79 100
Quiché Nebaj 4 26 30
Chajul 5 15 20
Cotzal 3 24 27
Sacapulas 7 5 12
Cunén 3 0 3
Total number 22 70 92
Total percentage 24 76 100
Total Total number 43 147 190
Total percentage 23 77 100
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Table 7. Sample Size of Pregnant Women, by Department, Municipality, and Program Participation (RVC or PEC)
Department Municipality
Number of participants from RVC communities
Number of participants from communities with
PEC presence Total
Huehuetenango Chiantla 2 5 7
San Pedro Nécta 1 10 11
San Sebastián Huehuetenango 2 7 9
Todos Santos Cuchumatán 1 10 11
Total number 6 32 38
Total percentage 16 84 100
Quiché Nebaj 0 7 7
Chajul 2 7 9
Cotzal 2 9 11
Sacapulas 1 5 6
Cunén 4 0 4
Total number 9 28 37
Total percentage 24 76 100
Total Total number 15 60 75
Total percentage 20 80 100
Table 8. Sample Size of Lactating Women, by Department, Municipality, and Program Participation (RVC or PEC)
Department Municipality
Number of participants from RVC communities
Number of participants from communities with
PEC presence Total
Huehuetenango Chiantla 3 4 7
San Pedro Nécta 3 11 14
San Sebastián Huehuetenango 3 7 10
Todos Santos Cuchumatán 1 7 8
Total number 10 29 39
Total percentage 26 74 100
Quiché Nebaj 3 9 12
Chajul 1 9 10
Cotzal 0 10 10
Sacapulas 4 4 8
Cunén 1 0 1
Total number 9 32 41
Total percentage 22 78 100
Total Total number 19 61 80
Total percentage 24 76 100
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Screening and Eligibility of Potential Participants
After randomly selecting the potential participating families, the INCAP study team visited them at their
homes, with the support of local personnel from the MSPAS PEC and/or RVC project. The INCAP study
team was introduced to the potential participating family and the purpose of the visit was explained. After
a potential participating family verbally accepted participating in the screening process, the eligibility of
the participant was assessed with a screening form for mothers and children (Appendix 32 and
Appendix 33, respectively). Inclusion criteria for participation in the data collection included: a) children
6–23 months of age and b) pregnant or lactating women at least 18 years of age at the time of contact.
Exclusion criteria for the study were: a) child born with congenital malformation or other disability
(physical or mental) or b) child experiencing a severe illness. Immediately after the screening was
conducted and the consent form was signed, the interview was carried out by project staff.
When the desired number of recruited families was achieved in each community, the recruitment
activities were stopped and the field staff moved on to the next selected community.
2.1.4 Training of Data Collectors
Field supervisors with nutrition training (e.g., registered dieticians) planned and conducted the data
collection in the field. Data collection staff trained in dietary assessment were in charge of the 24-hour
recalls. Eight data collectors were trained on the specific methodology of the project. The data collection
staff were educated personnel with extensive experience conducting health and nutrition surveys,
including anthropometrics and dietary assessment using the 24-hour recall methodology. Data collection
staff were under the supervision of two nutritionist field supervisors and one nutritionist serving as field
coordinator. The study training involved a period of 2 weeks of group sessions with presentations on the
nature and objectives of the study, procedures, logistics, etc. Specific sessions were dedicated to the
review of survey forms question by question. During these sessions, practice exercises were completed,
followed by supervised simulations with women volunteers. Training in dietary assessment involved a
review of the users’ manual with supervised practice exercises, first among the trainees and then with
women volunteers. For anthropometric measurements, the training sessions were focused on
standardization of the trainees in the measurement of length and weight in children and height and weight
in women. There were also practice sessions with volunteer children.
The training sessions were conducted by the study investigators (M. Mazariegos; V. Echeverría), with the
support of an experienced trainer (B. Sulecio).
2.1.5 Data Collection Methods
The cross-sectional survey of the four target groups took place from July to September 2012. The
majority of data collection took place during the lean or hungry season (Mazariegos and Méndez 2013) in
Guatemala, which is from mid-March through August. The implications of the data collection during the
hungry season are discussed in the results section. Fieldwork was conducted from Monday through
Saturday to ensure representation of normal week days and market days.
2.1.6 Data Collection Tools
Several tools were used to fulfill the specific aims of the study, including a survey tool to collect data on
socioeconomic status, demographics, and health; a food security survey, a tool to collect anthropometric
data; a 24-hour dietary recall tool to collect dietary data; and an adaptation of the ProPAN survey
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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modules17 to collect cost data from local markets. While the socioeconomic, demographic, and health
survey tool and the food security survey were not required for the Optifood analysis, they were included
by FANTA and INCAP to provide contextual data for the interpretation of the Optifood results. The tool
to collect anthropometric data was essential to provide average weight of respondents to calibrate energy
and protein requirements to body size as part of the Optifood analysis, as well as to provide information
about the current nutritional status of the population studied. Dietary data collected using the 24-hour
recall tool was necessary to determine a list of foods consumed by the studied groups and dietary patterns
(serving size and frequency of consumption) to provide a basis for the Optifood analysis. Finally, the
ProPAN market cost tool was used to provide a price per each 100 edible grams of the foods reported as
being consumed by the target population so that Optifood could estimate the affordability of
recommended diets. These tools are described in more detail below. The time required to collect the data
in each household was approximately 45–60 minutes. All data collection took place in participants’
homes, except for the collection of the data on food costs, which took place in major local markets in each
municipality.
Tool to Collect Socioeconomic Status, Demographics, and Health Data and Tool to Collect
Anthropometric Data
As mentioned, a survey tool that included questions on socioeconomic status, demographics, and health,
and a tool to collect anthropometric data were used to obtain an overall description of characteristics of
the sample of pregnant and lactating women and children 6–23 months of age and their households
(Appendix 34). These tools had been developed and tested by INCAP and had been used for similar
surveys that INCAP had conducted. The purpose of the anthropometric data was to quantify the
nutritional status of the target population, and to use the data on average body weight for specific target
groups to determine recommended calorie and protein needs per kilogram of body weight in the Optifood
program. An assessment of household food insecurity was carried out using a standardized questionnaire
developed by FANTA, the HFIAS, which complemented the data inputs for the Optifood program by
informing the potential feasibility of Optifood FBRs to improve nutrient intake in the target population
(Ballard et al. 2011). The survey tools were applied with the pregnant woman, the lactating woman with a
child under 6 months of age, or the mother or caregiver of a child 6–23 months of age in the household.
The information was recorded using a paper data form and pencil.
24-Hour Dietary Recall Tool
The 24-hour dietary recall was carried out using INCAP’s instruments (Appendix 35) and methodology
(Méndez 2012) (Appendix 36), with an adaptation to include a question on the weekly frequency of
consumption of the foods listed in the 24-hour dietary recall. The dietary assessment was carried out to:
1. Collect inputs needed for use in the Optifood software, including a list of foods consumed by
each target group, the median serving size, and the weekly frequency of consumption
2. Compare the current dietary practices with nutritional recommendations using INCAP´s Dietary
Recommendations (INCAP 2012), and identify nutrient adequacy of the current diet practices
The INCAP methodology for the 24-hour dietary recall required the recording of all food items, either
single foods or recipes for foods prepared in the home, that were eaten by the individual on the previous
day, as well as the estimated or calculated serving sizes. The survey team recorded the main meals,
snacks, and, in the case of breastfed children, nursing episodes on the 24-hour recall form. Optifood
17 See information on ProPAN at http://www.paho.org/common/Display.asp?Lang=E&RecID=6048. The manual is aimed at
ministries of health, NGOs, and bilateral and international organizations interested in improving IYCF practices to prevent early childhood malnutrition, describes how to design an intervention, and reviews evaluation strategies.
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requires data on frequency of food intake, i.e., the number of times each food was consumed per week, so
each food item reported by the mother in the 24-hour recall was further investigated to determine the
frequency of consumption over the last week. The dietary assessment also included a few questions
following the 24-hour recall to determine if there were other foods not mentioned in the 24-hour recall
that are regularly consumed. For these foods, the frequency of consumption and estimated median serving
size were recorded. Examples of standard portion sizes were used in the field (spoons and cups), as were
digital scales for weighing foods. Although data collection for the 24-hour recalls was not staggered, there
was good representation of the diet from regular weekdays, weekends, holidays, and market days.
Market Prices Survey Tool
The Market Prices Survey Form (Appendix 37) was adapted from a standardized instrument from
ProPAN (PAHO 2013) to collect information on the local market costs of foods identified in the 24-hour
dietary recall. The market prices survey involved recording the cost of foods in the main market of each
of the nine municipalities included in the study. For each food, data were collected, primarily in the
morning, on the local food name, prices from various vendors in the market to calculate the average price
in the market, and weights to determine price per weight. The average cost per 100 g of the edible portion
of each food item was determined for the survey area and this average cost was entered into the Optifood
program.
2.1.7 Recruitment Rates
A total of 1,688 potentially eligible participants were identified in the selected communities. Of these, 727
(43% of potentially eligible participants) were contacted, from which 604 (83% of contacted participants)
were screened, 569 (78% of contacted participants) were eligible, 569 (100% of eligible participants)
consented to participate, and 553 enrolled (76% of contacted; 97% of eligible). A total of 547 participants
completed the study and were included in the analysis. Of this total, 392 were children, of whom 202
were 6–11 months of age and 190 were 12–23 months of age, and 155 were women, of whom 75 were
pregnant and 80 were lactating. A total of 16 persons (2.8%) refused to participate. The primary reasons
for refusal included a lack of time or of interest in participating. One withdrawal case was reported. In six
cases, the 24-hour dietary recalls or other key information was missing in the data forms, and, therefore,
these six cases (1%) did not enter into the analysis.
Twenty percent of the final sample was obtained from lists of families participating in the RVC, while the
rest (80%) were recruited through the PEC program listings. It is important to clarify that the families
participating in the RVC (economic productive activity) could also be part of the PEC program coverage
that provided basic preventive health services.
2.1.8 Data Quality
Data quality assurance procedures were performed at the field level by supervisors. Completed data forms
were reviewed daily. Usually, at the end of the day when the staff returned from field, the supervisor (a
nutritionist/field coordinator) reviewed all data forms completed during the day. Completed paper data
forms were sent weekly to the INCAP data center in Guatemala City. A senior staff person from INCAP
reviewed the data and worked closely with field staff to ensure the quality of the data collected and
entered. A trained data processing team entered the data into the specific databases following
standardized quality assurance procedures, including double entry, use of summary reports, checking for
outliers, etc.
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2.1.9 Data Analysis
Analysis of the dietary data was carried out using SAS software version 9.2. The analysis included the
calculation of macronutrient content of foods consumed, such as energy, protein and fat, and
micronutrients, especially those considered key nutrients that may be lacking in the diet, such as iron and
zinc, based on actual intake from the 24-hour dietary recalls. These analyses used the food nutrient values
from the INCAP Food Composition Tables for Central America and Panama (INCAP 2007). The
adequacies in terms of micronutrient intake were calculated for the target groups—children 6–11 months
of age, children 12–23 months of age, and pregnant and lactating women—using INCAP Daily Dietary
Recommendations (INCAP 2012).18
2.2 Step 2 – Complete Analysis: Methods for Conducting Analysis Using Optifood
2.2.1 Data Entered into Optifood and Model Parameters
Optifood analysis is based on actual dietary patterns of the target groups. Therefore, data related to actual
dietary patterns are necessary for Optifood to set the model parameters that will constrain FBRs to what is
realistic. (FBRs are defined by the number of required servings per week from individual foods, food
subgroups, or food groups to meet, or come as close as possible to meeting, nutrient needs.19) In addition
to data on dietary patterns, Optifood requires reference values for RDA values and the nutrient content of
all the foods that are used for modeling diets. The data requirements for Optifood and their sources for the
analysis presented in this report are summarized in Table 9.
18 Note that Optifood provides adequacy of nutrient intake based on dietary patterns, while the data analysis on adequacy of
micronutrient intake conducted with SAS was based on actual intake from the 24-hour dietary recalls, adjusted for intra-
individual variability given only one 24-hour dietary recall was conducted for each respondent. 19 Each food in the Optifood FCT is categorized according to 1 of 17 food groups and 1 of the respective food subgroups. Food
groups include: grains and grain products; bakery and breakfast cereals; roots; legumes; dairy; meats; fruits; vegetables; fats;
sugars; sweets; beverages; miscellaneous (such as condiments, herbs, and sauces); composite meals (e.g., recipes); special
fortified products (such as a multiple MNP, lipid-based nutrient supplements); human milk; and savory snacks (such as salty,
spicy, or fried snacks). An example of food subgroups includes for fruits: vitamin A source fruits, vitamin C-rich fruits, and other
fruits. Each food group has at least one food subgroup that starts with the label “Myfoods_Special and ends with the name of the
food group for new or user-defined categories; for example, there is a fruit subgroup call “Myfoods_Special_Fruits and a dairy
subgroup called Myfoods_Special_Dairy’ The user may use a “special” subgroup to differentiate between any new or unique
food being added to the dietary list, compared to regular foods. Examples of “special” foods include chia seeds, amaranth, or fortified foods.
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Table 9. Data Requirements for Optifood and the Sources of These Data
Data Requirements Data Sources
List of foods For each food:
Median serving size (g/day or g/meal)
Maximum number of times per week consumedb
Cost per 100 g of the edible portion
Food group patterns (low, average (median), and high numberc of servings per week from different food groups) Food subgroup patterns (low and high number of servings per week from different food subgroups)d
24-hour dietary recalla
24-hour dietary recall
24-hour dietary recall
Market prices survey
24-hour dietary recall 24-hour dietary recall
RDA INCAP Daily Dietary Recommendationse
FCT values
INCAP Central American FCT f Optifood FCT U.S. Department of Agriculture (USDA) FCTg USDA Retention Factorsh
a 24-hour recall was collected in the cross-sectional survey described in Section 1. b 24-hour recall included a question on the frequency of consumption during the past week for each food reported during the 24-hour recall. c Low, average, and high servings of different food groups defined as the 10th, 50th, and 90th percentiles of consumption of foods from each food group. d Low and high number of servings of food subgroups defined as the 10th and 90th percentiles of consumption of foods from each food subgroup. e INCAP. 2012. f INCAP. 2007. g USDA. 2005. h Nutrient content of raw foods in the Guatemalan FCT, which were consumed in a cooked state, were adjusted for cooking losses using the retention factors presented in: USDA. 2007.
To prepare data for entry into Optifood, summary statistics from the cross-sectional survey were first
generated in MS Access.20 The outputs from MS Access were:
A list of foods consumed by the target group
The number and percentage of participants who consumed each food
The median serving size for each food expressed in grams per day and grams per meal
The 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles for the number of food servings per week
from Optifood specific foods groups21
The 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles for the number of food servings per week
from Optifood specific food subgroups22
Prior to entering the data into Optifood, the dietary patterns of children 6–8 months old and children 9–11
months old were compared and found to be significantly different. Therefore, the original target group of
children 6–11 months old was split into two groups (6–8 months and 9–11 months). In addition, almost
all of the children 6–11 months old were breastfeeding, so those who were not breastfeeding were
20 The MS Access program to calculate the Optifood inputs was provided by Elaine Ferguson of LSHTM in November 2012. 21 These 7-day estimates were calculated by multiplying the 1-day 24-hour recall data by 7; they were estimated on both a per day and a per meal basis. 22 These 7-day estimates were calculated by multiplying the 1-day 24-hour recall data by 7; they were estimated on both a per day and a per meal basis.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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excluded from the analysis. The dietary pattern of children 12–23 months old who were not breastfeeding
was also found to be different than children of the same age who were breastfeeding. Therefore, this age
group was split into breastfed and non-breastfed children 12–23 months old. The sample sizes of each of
the resulting six target groups are shown in Table 10.
Table 10. Sample Sizes of Target Groups by Department
Department Breastfed
6–8 months Breastfed
9–11 months Breastfed
12–23 months Non-Breastfed 12–23 months
Pregnant Women
Lactating Women
Huehuetenango 60 35 70 27 38 38
Quiché 50 47 71 21 30 41
Total 110 82 141 48 75 79
As a result of separating the children into age groupings, the sample size for each age group was very
small for each department. Therefore, to have sufficient data to define the model parameters, it was
necessary to combine data for the two departments. Before combining the departments, the dietary
patterns of the target groups across the two departments were compared (see Section 3.1). The most
commonly consumed foods were very similar for all of the target groups; there are no region-specific
foods. Therefore, it was assumed that FBRs developed using Optifood could be applicable to both
departments.
Food Lists
A list of foods for each target group was entered into Optifood. The inclusion criteria for these lists were:
The food was consumed by ≥ 5% of the target group.
The food was consumed by < 5% of the target group, but it was a good source of nutrients, it could
be promoted for consumption, and a similar food was not already included in the food list based on
the first criterion, i.e., consumed by ≥ 5% of the target group.
The exclusion criteria from these food lists were:
Water
Condiments consumed in small amounts
Breast milk was added to the food lists for target groups of breastfed children.
Overall, 210 foods were consumed by the study participants. The most commonly consumed foods were
sugar (fortified with vitamin A) (consumed by 78%–97% of each target group), tomatoes (58%–84%),
coffee (53%–88%), tortilla prepared from white maize (64%–74%), onion (54%–64%), reconstituted
dehydrated soup (35%–51%), vegetable oil (24%–56%), and potatoes (without skin) (35%–51%).
From these 210 foods, 61 were selected to be used in the Optifood analysis (see Appendix 12): 50
because they were consumed by ≥ 5% of a target group and 11 because, while they were not commonly
consumed, they were nutrient-dense foods that were found to be present in the area and therefore could be
promoted for consumption to improve diet quality in a target group (see starred foods in the table in
Appendix 12). The food lists, however, varied for each target group, ranging from 42 foods for children
9–11 months old to 49 foods for non-breastfed children 12–23 months old.
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Food Serving Sizes
The median observed serving size of each food was entered into Optifood (see Appendix 12). Food
serving sizes were defined on a meal basis (g/meal) or on a day basis (g/day), depending on the food
group. A day-basis serving size was used (g/day) for all foods except those in the food group “Grains and
Grain Products.” The meal-based serving size (g/meal) was used for foods in the “Grains and Grain
Products” food group because there was great variation in the number of times foods from this group
were eaten per day and foods from this food group provided substantial amounts of energy, so it was
important to accurately represent amounts consumed each day and allow for more precision in defining
the food patterns for this food item. For example, tortillas were usually eaten two times per day and
tamalitos eaten one time per day. For children 6–8 months of age, a serving of tortilla was 13 grams,
usually consumed twice per day, while a serving of tamalito was 35 grams, usually consumed once per
day, so the median daily portions of tortilla versus tamalito represented significantly different serving
sizes. For all food groups, a serving size was defined by the median daily (g/day) or meal-based (g/meal)
serving sizes generated in the MS Access outputs for each target group.
For foods modeled using a daily serving size, the serving sizes ranged from 0.4 g/day for coffee powder
to 460 g/day for pumpkin; those modeled using a meal-based serving size (i.e., all grains and grain
products) ranged from 4 g/meal for fortified instant oats to 414 g/meal for tamalito. Across all target
groups, the portion sizes for 55% of foods were estimated from 10 or more consumers, although 26% of
foods were estimated from fewer than 5 consumers.
Breast milk consumption was not measured in this study; instead, the estimations of average daily breast
milk intake for breastfed children 6–8 months old, 9–11 months old, and 12–23 months old was
determined by subtracting the median energy intake from complementary foods estimated from the
24-hour dietary recall data from the average energy requirements for each age group from the INCAP
Daily Dietary Recommendations, divided by the USDA standard energy content per gram of breast milk
(0.7 kcal/g) (INCAP 2012; USDA 2005) (Table 11).
Table 11. Average Breast Milk Intake per Day Input in Optifood by Target Group
Average energy
requirements (kcal) Median energy intakes from complementary foods (kcal)
Average breast milk intake (g/day)
Breastfed children 6–8 months (n=111)
620 268 (620 − 268) / 0.7 = 503
Breastfed children 9–11 months (n=83)
700 353 (700 − 353) / 0.7 = 496
Breastfed children 12–23 months (n=142)
850 512 (850 − 512) / 0.7 = 483
Food Frequency
In Optifood, the minimum and maximum numbers of days per week that each food can be consumed are
defined based on the 24-hour recall findings, to help ensure the development of realistic FBRs. These
frequencies are multiplied by the food’s median daily serving size to define the lowest and highest
quantities (g/week) of each food that can be realistically included in each diet. In general, the minimum
frequency for all foods was 0, i.e., a diet can be selected without the food in it. The exception was a food
that was eaten by all individuals in a target group, which in this study was breast milk for the three target
groups of breastfed children. For these children, the minimum frequency for breast milk was 6.9 servings
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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per week and the maximum frequency was 7.0. (A value of 7.0 was not used for the minimum frequency
because the minimum and maximum values must be different for the analysis to run.)
For each food, the maximum frequency was defined as the 90th percentile of each target group’s food
frequency distribution. (See Appendix 12 for the maximum frequency for each food entered into
Optifood.) These percentiles were generated from the food frequency data collected for foods reported in
the 24-hour recalls. In cases where a food was eaten more than once a day, the highest frequency was
used, i.e., if a food was eaten 2 times per week at lunch and 5 times per week at dinner, a maximum
frequency of 5 times per week was entered into the database. In cases where a food was not eaten, a value
of 0 was entered in the database. Thus, for any individual, the maximum weekly frequency for each food
could range from 0 times per week (food not consumed) to 7 times per week.
To generate the maximum frequencies for foods in the “Grains and Grain Products” food group, that is,
foods where serving sizes were defined in grams per meal, the maximum frequency was defined as the
90th percentile of each target group’s food frequency distribution adjusted to a per meal basis, rather than
a daily basis.23
Food Groups and Food Subgroups
In Optifood, constraints are set on the number of servings per week from individual food groups and food
subgroups to ensure that the diets modeled conform to the observed target group’s food pattern ranges.
For each food group, the minimum, average,24 and maximum number of servings per week was defined
by the 10th, 50th, and 90th percentiles generated by the MS Access program, and then the data were
entered into Optifood. For food subgroups, the minimum and maximum number of servings per week was
defined by the 10th and 90th percentiles generated by MS Access and then entered into Optifood. The
minimum, median, and maximum number of servings per week for food groups and minimum and
maximum number of servings per week for food subgroups for each of the target groups is shown in
Appendix 13 and Appendix 14, respectively.
For all food groups except “Grains and Grain Products,” the 10th, 50th, and 90th percentiles from the
MS Access outputs were expressed on a daily basis. For “Grains and Grain Products,” the 10th, 50th, and
90th percentiles from the MS Access outputs were expressed on a meal basis.
For several food groups and food subgroups, the lowest level constraint was 0, meaning a diet can be
selected that does not include these foods. In cases where the 50th percentile for the food group was 0, a
value of 1 was entered in Optifood to avoid mathematical divisions by 0. In cases where the 10th, 50th,
and/or 90th percentiles were identical, adjustments were made to the lowest and highest number of
servings per week because the low, average, and high number of servings per week values that are entered
into Optifood must differ. For example, the lowest number of servings from the food group/subgroup was
adjusted to the 10th percentile value minus 1, the highest number of servings from the food group/food
23 Specifically, the frequency of consumption on a per meal basis is calculated in the following way: a) if the 90th percentile was
fewer than 7 servings per week and the size of a serving at a meal and the size of the serving for the entire day were similar, the
simple 90th percentile was used; b) if the 90th percentile was 7 servings per week and the size of the serving at a meal and the
size of the serving for an entire day were different, the 90th percentile values were adjusted based on the ratio of the day-based
serving size to the meal-based serving size. So if the day-based serving size of tortilla was 26 grams and the meal-based serving
size of tortilla was 13 grams, a ratio of 2 (26/13) was used to adjust the 90th percentile on a grams/day basis to a grams/meal basis, so a maximum frequency of 7 times per week would be adjusted by a factor of 2, to 14 times per week. 24 In the Optifood program, the labels minimum, average, and maximum are used to define the constraints for food groups. The
values given for “average” constraints are defined by the 50th percentile or median consumption of items from a food group by members of a target group.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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subgroup was adjusted to the 90th percentile value plus 1, and the average number of servings for the
food group (i.e., the food pattern goal) was equal to the value observed (i.e., the 50th percentile).
Food Cost
The cost per 100 g of the edible portion for each food was entered into Optifood based on the cost data
from the market prices survey completed by INCAP. Appendix 12 includes the cost per 100 g of the
edible portion for each food.
Dietary References
RDA values, adequate intake (AI) values, and protein and energy requirements found in the INCAP Daily
Dietary Recommendations were entered into Optifood for each of the target groups (Appendix 15)
(INCAP 2012). The RDA is defined as the average daily dietary nutrient intake level that is sufficient to
meet the nutrient requirements of nearly all (97%–98%) healthy individuals in a particular life stage and
gender group (Otten et al. 2006). The RDA is set by adding two standard deviations (SD) to the estimated
average requirement (EAR). The EAR is the average daily nutrient intake level that is estimated to meet
the nutrient needs of half of the healthy individuals in a life stage or gender group (Otten et al. 2006).
When an RDA cannot be determined, an AI value is used. The AI is the recommended average daily
intake level based on observed or experimentally determined approximations or estimates of nutrient
intake by a group (or groups) of apparently healthy people that are assumed to be adequate (Otten et al.
2006). To simplify language in this report, “RDA” refers to both RDA and AI values.
Food Composition Table
An FCT based on the INCAP Central American FCT was created and entered into Optifood (INCAP
2007). The new entries added to the Optifood FCT were carefully scrutinized for missing or incorrect
values; any such entries were then imputed from either the Optifood FCT or the USDA FCT database
(USDA 2012), after adjusting for the differences in moisture, using the USDA retention factor, that result
from cooking. The sources for these imputed values were recorded in the comments section of the user-
defined Guatemalan food composition values in the Optifood FCT. Zeroes or missing values in the
INCAP Central American FCT for folate were also scrutinized.25 If data for folate were not available in
the INCAP FCT, values were imputed from the USDA database, after adjusting for differences in
moisture. Folate values were not taken from the USDA database for cereals because of the practice of
folate fortification in the United States.
For Incaparina,26,27 the food composition values were calculated from packet information of Incaparina
“Tradicional,” the version of Incaparina designed for the general population that was consumed by all six
target populations. Finally, in the INCAP Central American FCT, values appeared unrealistically high for
the iron content of potatoes and the riboflavin content of tamalitos28 prepared from yellow and white corn.
25 Missing values for folate in the INCAP FCT were due to lack of availability of the data when they were sourced externally for
the INCAP FCT. 26 Incaparina is a fortified corn- and soy-based flour commercially produced in Guatemala by Alimentos S.A. It is fortified with
iron, zinc, calcium, thiamine, riboflavin, niacin, vitamin B12, vitamin B6, folic acid, and vitamin A in four formulations.
Incaparina is consumed by family members, as a complementary food for children 6–23 months, and by pregnant and lactating women. 27 Vitacereal, a complementary food similar to Incaparina, was not included in the Optifood analysis as it did not appear in the
observed diets. At the time of data collection Vitacereal was not yet being distributed by the GOG. See Section 3.4.8 for further discussion of Vitacereal. 28 Tamalitos are a maize-based food prepared in a similar manner to tamales. Stone-ground, nixtamalized maize dough is wrapped in plantain leaves or corn husks and steamed.
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For potatoes and tamalitos, realistic values were imputed from similar foods in the USDA and INCAP
FCTs, after adjusting for differences in moisture.
Food composition values in the INCAP Central American FCT are for foods in their raw state. To avoid
overestimating nutrient intakes from foods consumed in their cooked state, their nutrient values were
adjusted for cooking losses using the USDA retention factors (USDA 2007). These adjustments meant
that the food composition database uploaded into Optifood contained nutrient values for raw foods that
were adjusted to reflect losses during cooking. These food composition data were appropriate because the
food consumption data, for ingredients from cooked foods, were recorded in the equivalent of their raw
ingredient weights.
2.2.2 Data Analysis in Optifood
Module 1: Check Diets
After entering the data described above for each target group, Module 1 of Optifood was run and the
outputs were examined. Module 1 tests the constraints previously set in the food lists, food groups, and
food subgroups to ensure that there is sufficient flexibility in food choices for modeling diets and to
ensure at least some individuals from the target population could consume the diets generated by
Optifood. If any of the resulting test diets were deemed to be unrealistic, changes were made to the model
parameters to ensure that the modeled diets could realistically be consumed by the corresponding target
population.
Changes Made from Observed Food Patterns. Several model parameters were changed to ensure
consistency in terms of average servings per week (food groups only) and upper and lower limits of
servings per week (food groups, food subgroups, and individual foods), or to test an FBR that included a
food that was not in an original food list for a target population.
For breastfed children 6–8 months old:
o The maximum frequency constraint on fortified instant oats29 was increased from 1 to 7
servings per week to test the FBR of 2 servings per day of fortified grains (i.e., Incaparina and
fortified instant oats).
o The maximum constraint on vitamin C-rich fruits was increased from 1 to 7 to be consistent
with the maximum frequency constraint on lemons and oranges.
o A minimum of 3 servings of “Added Sugars” was set to correspond with the minimum servings
(5) observed for other target groups.
For breastfed children 9–11 months old:
o No changes were made
For breastfed children 12–23 months old:
o Constraints for vegetable subgroups were increased to ensure consistency with the overall
vegetable food group and individual food constraints (increased by 1 for “other vegetables”
and by 2 for “vitamin A-source vegetables”).
For non-breastfed children 12–23 months old:
o To ensure consistency with the Optifood constraints for the food group “animal source foods,”
the maximum numbers of servings for individual foods in this group were increased by 0.5
servings/week for lamb (from 0.5 servings/week) and by 1.0 serving/week for eggs and
chicken (from 4 and 1 servings/week, respectively). Similarly, the individual food constraint
29 The instant fortified oats consumed by the target population and analyzed by Optifood in this project are fortified with iron,
zinc, calcium, vitamin B12, niacin, folic acid, thiamine, and vitamin A.
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for “black beans” was increased from 3 to 7 servings/week to correspond to the constraints for
the legume food group.
o The maximum numbers of servings per week for fortified instant oats and Incaparina were
increased to 7 for each one (from 3 and 1 servings/week, respectively) to test an FBR of
2 servings per day of fortified grains.
For pregnant women:
o While not consumed by pregnant women in the sample, liver was added to the food list for this
target group to enable the evaluation of a liver FBR. The serving size and constraints were set
using the values for liver in the food list for lactating women.
For lactating women:
o No changes were made
In addition to these changes, all grains that could be prepared as atoles30 were categorized into a “Special
Grains” food subgroup to limit the number of atoles selected in a 7-day diet to ≤ 2 servings per day. Only
tortillas and tamalitos were classified as staples, and the lowest constraint level for staples was set as
≥ 7 servings per week.
Module 2: Identify Draft Recommendations
To fully explore the diets of and potential recommendations for the study population, four types of
analysis per target group were run in Module 2. For each analysis the two best diets were generated.
1. In the first analysis, the food list included all foods originally selected for the Optifood analysis,
as guided by the results of the 24-hour recalls in the cross-sectional survey.
2. In the second analysis, highly fortified foods—Incaparina and fortified instant oats—were
excluded from the food list.
3. In the third analysis, the FAO/WHO (2004) and WHO/FAO/United Nations University (UNU)
(2007) recommended nutrient intakes (RNIs) for micronutrients and protein were used for all
child target groups instead of the INCAP Daily Dietary Recommendations. For pregnant and
lactating women, the INCAP recommendations were replaced with the Institute of Medicine
(IOM) 2001 (USA-Canada) (National Research Council 2001) estimates adjusted for low
bioavailability of iron in the diet.
4. In the fourth analysis, the International Zinc Nutrition Consultative Group (iZiNCg) RDAs
(Brown et al. 2004) for zinc, assuming low bioavailability, were used instead of the INCAP
RDAs for zinc. For all other nutrients, in this fourth analysis, the INCAP Daily Dietary
Recommendations were used.
The first analysis was used to identify the best food and food subgroup sources of micronutrients in
existing diets, based on current food supply; to formulate and test the FBRs; and to generate the lowest-
cost nutritionally best diets using Modules 3 and 4. The additional analyses (Steps 2–4 above) were
carried out to provide information on whether or not nutritionally adequate diets could be selected using
unfortified local foods alone (second analysis) and to assess the sensitivity of results to the dietary
reference values used (third and fourth analyses).
30 Atole is a traditional hot, cereal-based beverage, commonly used to feed children and pregnant or lactating women. It is usually
prepared with water, sugar, and a ground cereal, legume, or maize flour in a diluted form, and is the most common and accepted
way of preparing Incaparina and Vitacereal (Estrada et al. 2007). The preparation of food as atole has been recognized as a
contributor to protein malnutrition in young children because of the low protein content of flours commonly used (corn, rice, or yucca/starch) and the tendency for over-dilution (Barenbaum et al. 2001).
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In all analyses, Module 2 was initially run to select the two best diets:
Diet A: A diet that comes as close as possible to achieving the target population’s RDAs for
selected nutrients while adhering to the set dietary patterns as much as possible (defined by median
consumption for food groups, set at 50th percentiles of observed consumption, labeled as “average”
consumption in the Optifood software)
Diet B: A diet that comes as close as possible to meeting the target population’s RDAs, without
taking dietary patterns into account
The selected nutrients for both diets included protein; calcium; iron; zinc; vitamins A, C, B1, B2, B3, B6,
and B12; and folate. They also included achievement of 30% of energy from fat. If the RDAs and/or
“average” food pattern goals31 were achievable, for any target group, then the diet’s cost was also
minimized to select the best diet.
The results from these analyses, specifically the differences between Diets A and Diets B, were used to
identify problem nutrients, i.e., nutrients for which the requirements are not able to be met using local
food sources. The first analysis (analysis that included Incaparina and fortified instant oats) was also used
to help formulate draft FBRs to test and compare using Module 3. The draft FBRs were selected using a
systematic process that included:
An examination of the changes that occurred in food group patterns in order for nutrient
requirements to be met
Identification of the best food sources of nutrients and subgroup sources of nutrients as per the
results of Diets B
The draft individual FBRs defined the number of servings per week of individual foods, food subgroups,
and/or food groups, and are described below.
Module 3: Test Draft Food-Based Recommendations
Before testing the draft FBRs, Module 3 was first run without adding any new constraints (i.e., based on
observed [low or average consumption] dietary practices as opposed to diets that included any FBRs) to
provide a benchmark diet against which to compare different FBRs. This benchmark diet could be used to
compare nutrient levels when testing each FBR to assess whether the percent RDA of each nutrient that
was being covered in the worst-case scenario32 was a significant improvement compared to the existing
practices. This first run was also used to distinguish between problem nutrients, resulting in a list of
“absolute” and “partial” problem nutrients, as described below.
The Module 3 analysis generates 34 diets per run. In one set of diets (17 of the generated diets), energy
and each nutrient were individually maximized to show the nutrient levels that could be achieved in the
best-case scenario; a nutrient’s highest achievable level in any diet, expressed as a percentage of its RDA
(e.g., a diet with the highest achievable calcium content, a diet with the highest achievable protein
content, etc.). The best-case scenario nutrient levels from these analyses were used to define the absolute
and partial problem nutrients. An absolute problem nutrient was defined as a nutrient whose best-case
scenario level was less than its RDA (i.e., the RDA could not be met using local foods and local food
patterns). These nutrients will likely remain inadequate given the local food supply and the target
population’s food consumption patterns. Partial problem nutrients were defined as those whose best-case
31 Based on median or 50th percentile of consumption of particular food groups. 32 The “worst case scenario” refers to a diet with the lowest possible level of a nutrient (% RDA) possible, given minimum and
maximum constraints and any FBRs that need to be followed.
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scenario levels met or exceeded their RDAs, but whose levels in the Module 2 best diets were below their
RDAs, meaning that meeting the RDAs would likely have detrimental effects on the intake of other
nutrients given local food patterns because foods with other nutrients would need to be replaced by the
problem nutrient. In contrast, in the other set of diets (the remaining 17 diets), each nutrient was
individually minimized to show the worst-case scenario nutrient levels: a nutrient’s lowest possible level
in any diet, expressed as a percentage of its RDA (e.g., a diet with the lowest possible calcium content, a
diet with the lowest possible protein content, etc.).
The objective of the FBRs developed using Optifood is to promote a diet for the target group with the
highest level of nutrient adequacy possible, given local food availability and food patterns. The results of
Module 3 display the minimum (or “worst-case scenario”) percentage of RDAs for selected nutrients that
would be met if an FBR or a set of FBRs was put into practice. The criterion for determining whether a
particular FBR or set of FBRs will ensure nutrient adequacy is a worst-case scenario level of ≥ 70% of the
RDA for a particular nutrient. The worst-case scenario level simulates the lower tail, approximately the
5th percentile, of a nutrient intake distribution and aims to ensure that the prevalence of inadequacy in the
target group is no more than 2%–3%. The illustration in Appendix 31 uses iron intake among breastfed
children 6–8 months to illustrate this concept.
The choice of ≥ 70% of the RDA as the criterion of acceptability is somewhat arbitrary and lower cutoffs
have been used in other Optifood projects (Skau 2013).
However, the number of individuals in a target population at risk of inadequate nutrient intakes would
progressively increase as the worst-case scenario levels fell farther below 70% of the RDA.
The Module 3 analyses were done in three stages, for each target group, using a series of iterative steps in
each stage. In the first stage, a set of FBRs was chosen that would best ensure a nutritionally adequate diet
for the target population. In the second and third stages, this set of FBRs was carefully scrutinized to
determine the importance of each individual FBR in the set. In addition, in the third stage, alternative sets
of FBRs, based on different combinations of the individual FBRs selected in Stage 1, were tested to
determine the nutritional and cost implications of using a simpler set of FBRs than the final one selected.
Each of these stages is described below.
Stage 1. Stage 1 involved five steps.
1. Approximately 15 individual draft FBRs (number of servings/week for a food group, subgroup,
or individual food, e.g., 7 servings/week of dairy products), based on the Module 2 results, were
selected.
2. Each FBR was tested using the Module 3 analyses.
3. The worst-case scenario results for each FBR were compared on the basis of micronutrients (% of
RDAs) and cost to select subsets of FBRs for further testing. The criteria for selecting individual
FBRs for combination into subsets of FBRs were that their worst-case scenario level was ≥ 70%
of the RDA for a particular nutrient or, when none of the FBRs tested achieved 70% of the RDA
for a nutrient, FBRs with the highest worst-case scenario levels were selected.
4. The subsets of FBRs were tested together via the Module 3 analyses.
5. The worst-case scenario results for the subsets were again compared on the basis of
micronutrients and costs.
Iterations of Steps 3 and 4 were continued until a final set of FBRs was selected for each target group.
The criteria used to select the final set of recommendations were cost, worst-case scenario nutrient levels
(i.e., ≥ 70% of the RDA), simplicity/feasibility (a subjective judgment in which more general
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recommendations were favored over recommending specific foods and commonly consumed foods were
favored over rarely consumed foods), and consistency with FBRs selected for other similar target groups.
The aim was to select a practical set of FBRs for each target group that would ensure a nutritionally
adequate diet, while also being as inexpensive as possible. An additional goal was to make the
recommendations similar to those of other similar target groups (i.e., similar recommendations for
breastfed and non-breastfed children 12–23 months) to facilitate their promotion.
Stage 2. Once a set of FBRs was selected for each target group, the nutritional importance of each
individual FBR within the set was assessed. In this stage, an iterative process was used in which each
FBR was individually removed from the entire set of FBRs and the Module 3 analyses were run. The
worst-case scenario values for each nutrient were examined to determine if any fell below 70% of their
RDAs when an individual FBR was removed from the set. For some FBRs, these analyses were also done
with a reduced number of servings per week (e.g., oranges 3 times/week instead of oranges 7 times/
week). These analyses confirmed the nutritional importance of each FBR in the set of FBRs and that the
nutrient requirements they helped ensure were met.
Stage 3. In the final analyses, the nutritional and cost implications of selecting alternative sets of FBRs
that recommend fewer foods than were originally proposed were evaluated, and the nutritional importance
of each individual FBR within the set of FBRs chosen in Stage 1 was again confirmed. In this stage, each
individual FBR from the set of FBRs chosen in Stage 1 was systematically combined with other
individual FBRs to create sets with one, two, three, four, five, and six FBRs. These analyses covered all
possible permutations of the individual FBRs selected in Stage 1. In these analyses, the worst-case
scenario nutrient levels (expressed as percentage of their RDA) and the lowest-cost diets, for each
permutation, were examined. In addition, the best combinations of FBRs from a given number of
individual FBRs were identified. These combinations were selected on the basis of the number of worst-
case scenario nutrient levels that were ≥ 70% of the RDAs and the cost of their lowest-cost diet. For
example, the best set of FBRs containing two recommendations was identified, the best set of FBRs
containing three recommendations was identified, etc. These analyses were done to inform future
decisions with stakeholders regarding the final set of FBRs to promote in the Western Highlands.
Module 4: Cost Analysis
While it is possible to set cost as a constraint in the Optifood analysis, this was not used for this project as
the research question was focused on identifying the lowest-cost nutritionally best diet as opposed to
identifying the most nutritionally adequate diet possible for a particular budget.
Module 4 was run, for each target group, to identify the lowest-cost nutritionally best diet (a diet that was
modeled on meeting energy requirements and following existing dietary patterns only). This lowest-cost
diet was used as a baseline to explore the cost of adding individual or various sets of FBRs to the diet.
In this module, a linear programming model was first run to determine if all RDAs could be achieved in a
diet for the target population using local foods; where they could not be achieved, the highest level
achievable for that nutrient was determined. In the second analysis in Module 4, diet cost was minimized
with constraints imposed to ensure that a realistic diet according to observed food patterns was selected
(constraints on energy, foods, food groups, and food subgroups) and that the desired nutrient levels were
achieved (i.e., constraints on nutrients that were set at their RDA levels or the highest levels achievable
when their RDAs could not be achieved).
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3. Results
3.1 Results from the Cross-Sectional Survey and Information Gathering on Local
Dietary Patterns and Food Costs
3.1.1 Background Characteristics
Table 12 shows selected socio-demographic characteristics of households and women who were
surveyed.
Table 12. Selected Socio-Demographic Characteristics of Households and Women Surveyed
Characteristics Huehuetenango Quiché Total
Households
Number of people living in the household (mean) 7.3 7.4 7.3
House owned by respondent or spouse (% yes) 68.8 86.8 77.6
Flooring material is sand, dirt, or clay (% yes) 59.5 62.3 60.8
Access to electricity (% yes) 84.4 53.3 69.2
Household effects (% yes)
Radio 68.8 59.1 64.0
Television 34.2 25.7 30.0
Mobile telephone 82.9 78.2 80.6
Access to piped water (% yes) 74.4 90.7 82.3
Purify water using acceptable method (% yes)33 95.5 91.1 93.4
Access to latrine or toilet and sewage system (% yes) 87.4 77.9 82.7
Home garden (% yes) 24.3 45.1 34.5
Use of food produced in home garden (% yes)
Sold 7.8 4.4 5.5
Consumed 65.8 75.2 71.9
Sold and consumed 25.9 20.6 22.6
Livestock (% yes) 78.9 86.8 82.8
Type of livestock (% yes)
Chickens 93.3 96.9 95.1
Pigs 37.8 45.3 41.7
Goats/sheep 14.8 11.2 13.0
Cows 2.9 7.0 5.32
Use of livestock and/or livestock products (%)
Sold 10.4 16.1 13.3
Consumed 72.2 57.0 64.4
Sold and consumed 17.5 26.9 22.3
Women respondents
Age, years (mean) 26.2 27.8 26.9
Education (%) Primary or less 58.9 49.0 54.1
Never attended 28.2 42.0 34.9
Ethnic group is indigenous by enumerator observation (% yes) 72.9 99.6 85.9
Speaks Spanish (% yes) 79.9 53.7 67.1
Language of the interview (%)
Spanish 65.9 45.5 55.9
Ixil 0.0 33.9 16.7
Mam 34.1 0.0 17.3
Quiché 0.0 20.6 10.2
33 Acceptable methods of water purification were defined as boiling, using chlorine, or solar disinfection.
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Selected characteristics of children 6–23 months, pregnant women, and lactating women who participated
in the survey are shown in Table 13. Consumption by surveyed children of a multiple micronutrient
powder (MNP), known locally as “Chispitas,” in the 24 hours prior to the survey was low and it is
important to mention that the distribution of Chispitas by PEC was in its initial stage of implementation
when the survey was carried out. While most pregnant women surveyed were receiving micronutrient
supplements as part of their antenatal care, a smaller percentage of women reported receiving
micronutrient supplements postpartum. MSPAS protocols include iron and folic acid supplementation for
pregnant women and for women 6 months postpartum (MSPAS 2004).
Table 13. Selected Characteristics of Children 6–23 Months, Pregnant Women, and Lactating Women Surveyed
Characteristics Huehuetenango Quiché Total
Children 6–23 months
Sex (% male) 47.5 49.7 48.6
Age, months (mean) 13.0 13.4 13.2
Consumed supplement in the last 24 hours (% yes)
Iron 9.2 3.9 6.5
Folic acid 3.9 2.3 3.1
Chispitas 1.5 37.7 19.6
Pregnant women
Number of completed months of pregnancy (mean) 6.1 6.6 6.4
Received some form of supplement in last month (% yes) 81.6 86.8 84.2
Reports regularly consuming supplement in last month (%)
Iron 70.6 73.7 72.2
Folic acid 58.8 63.2 61.1
Multiple micronutrient 20.6 13.2 16.2
Currently breastfeeding (% yes) 5.4 7.9 6.7
Lactating women
Received supplements from postnatal care provider (% yes) 32.4 55.3 44.0
Reports regularly consuming supplement in last month (%)
Iron 45.8 41.0 42.9
Folic acid 29.2 46.1 39.7
Multiple micronutrient 8.3 2.6 4.8
3.1.2 Household Hunger and Food Security
Food insecurity was measured through two different tools, the Household Hunger Scale (HHS), which
focused on lack of food in the household, and additional survey questions on any existing anxiety or
concerns about accessing sufficient food and affording a diverse diet (Ballard et al. 2011).34 The HHS
focuses on the food quantity dimension of food access and has been specifically developed and validated
for cross-cultural use. The HHS consists of three occurrence questions and three frequency-of-occurrence
questions. The HHS occurrence questions ask whether or not a specific condition associated with the
experience of food insecurity ever occurred during the previous 4 weeks (30 days). The HHS frequency-
of-occurrence questions ask how often a reported condition occurred during the previous 4 weeks: rarely,
sometimes, or often (see Table 14).
34 Additional questions regarding concern or anxiety regarding food security were derived from the HFIAS, which is also discussed by: Ballard et al. 2011.
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Table 14. Household Hunger Scale
Occurrence questions Frequency-of-occurrencea Huehuetenango Quiché Total
Reports not having food of any kind in house because of lack of money to buy food in last 30 days (%)
No 91.4 94.9 93.1
Yes
Rarely 6.0 3.1 4.6
Sometimes 2.6 1.6 2.1
Often 0.0 0.4 0.2
Reports household member going to sleep at night hungry (without eating dinner) because there was not enough money to buy food in the last 30 days (%)
No 94.8 92.6 93.7
Yes
Rarely 3.0 3.1 3.0
Sometimes 1.9 4.3 3.0
Often 0.4 0.0 0.2
Reports household member going a whole day and night without eating anything at all because there was not enough food in the last 30 days (%)
No 99.6 99.2 99.4
Yes
Rarely 0.4 0.8 0.6
Sometimes 0.0 0.0 0.0
Often 0.0 0.0 0.0
Household hunger categories and HHS (%)
Little or no hunger in the household (household hunger score of 0–1)
97.0 97.3 97.1
Moderate hunger in the household (household hunger score of 2–3)
3.0 2.7 2.9
Severe hunger in the household (household hunger score of 4–6)
0.0 0.0 0.0
HHS (median) 0.0 0.0 0.0
a “Rarely” is once or twice in the past 30 days.
“Sometimes” is 3–10 times in the past 30 days. “Often” is more than 10 times in the past 30 days.
According to responses to questions in the HHS, few households reported experiencing recent hunger—
defined as a lack of food in the household, members of the household going to sleep hungry, or members
of the family going without food for a whole day and night—in the last 30 days (Ballard et al. 2011).
Only 3% of households were classified as experiencing moderate hunger according to the HHS.
Responses to additional survey questions related to household food access are shown in Appendix 1. The
results of these questions indicate that roughly half of households experienced anxiety or concerns
regarding food insecurity in the 30 days preceding the survey. In Quiché, 84.4% of households reported
worrying about the amount of food in the household and 77.0% reported a family member eating a less
diverse diet, as compared to 53.0% and 45.5%, respectively, in Huehuetenango. Therefore, although few
households reported experiencing hunger according to the HHS, a large percentage of households,
especially in Quiché, reported experiencing problems with food access. This finding is important, as it
indicates that even when nutritious foods are locally available, they may not be accessible to a large
percentage of the households.
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3.1.3 Nutritional Status of Children 6–23 Months
Anthropometric data collected during the cross-sectional survey confirms the results of the 2008–09
ENSMI regarding the severity of chronic malnutrition in Huehuetenango and Quiché. Table 15 shows the
prevalence of stunting (low height-for-age), wasting (low weight-for-height),35 and underweight (low
weight-for-age).36 By the end of the first year of life, almost half of children in the sample (47.3%) are
already stunted. In the second year of life, the prevalence of stunting increases to 70.5% of children. The
prevalence of stunting among children 6–23 months is significantly higher in Quiché (64.3%) than in
Huehuetenango (52.9%) (p = 0.02).
35 Wasting is defined as weight-for-height < −2 SD from the median of the 2006 WHO Child Growth Standards; see
http://www.who.int/childgrowth/en/. 36 Underweight is defined as weight-for-age < −2 SD from the median of the 2006 WHO Child Growth Standards; see
http://www.who.int/childgrowth/en/.
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Table 15. Nutritional Status of Children 6–23 Months
Height-for-agea Weight-for-heighta Weight-for-agea
Background characteristic
Percentage < −3
Percentage < −2b
Mean z-score
Percentage < −3
Percentage < −2b
Mean z-score
Percentage < −3
Percentage < −2b
Mean z-score N
Age (months)
6–11 14.6 47.3 −1.92 0 0.5 0.15 2.5 17.1 −1.05 199
12–23 33.7 70.5 −2.58 0 2.1 −0.47 7.9 33.6 −1.65 191
Sex
Male 25.0 61.7 −2.35 0 1.1 −0.18 4.8 27.7 −1.4 188
Female 22.9 55.7 −2.14 0 1.5 −0.14 5.5 22.8 −1.29 202
Department
Huehuetenango 22.6 52.9 −2.1 0 1 −0.6 4.6 22.9 −1.23 197
Quiché 25.4 64.3 −2.35 0 1.6 −0.26 5.7 27.5 −1.46 193
Total 23.9 58.6 −2.24 0 1.3 −0.16 5.1 25.1 −1.34 390
a Each of the indices is expressed in SD from the median of the 2006 WHO Child Growth Standards. b Includes children who are below −3 SD from the 2006 WHO Child Growth standards population median.
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3.1.4 Nutritional Status of Women
Non-pregnant women were weighed and measured as part of the cross-sectional survey. Table 16 shows
the percentage of women with a body mass index (BMI) classified as underweight (BMI < 18.5), normal
(BMI ≥ 18.5 to < 25.0), overweight (BMI ≥ 25.0 to < 30.0), and obese (BMI ≥ 30.0). Approximately two-
thirds of non-pregnant women surveyed in Huehuetenango and Quiché had a BMI within a normal range
(67%) and almost one-third of women had a BMI classified as overweight or obese (29%). The
percentage of women classified as overweight or obese may be overestimated since the sample includes
lactating women with infants under 2 months.37 Few women were classified as underweight (4%).
3.1.5 Infant and Young Child Feeding Practices
Table 17 presents indicators of IYCF practices for breastfed children 6–23 months and non-breastfed
children 12–23 months. Almost all (96%) of the children 6–11 months old were breastfed at the time of
the survey. Among children 12–23 months old, 75% were being breastfed. Dietary diversity was low
among the children surveyed: only 36% of children 6–8 months old, 49% of children 9–11 months old,
and 37% of children 12–23 months old consumed food from at least four food groups in the 24 hours
preceding the survey (WHO 2008a).38 A smaller percentage of children in Quiché (32.1%) had adequate
dietary diversity as compared to Huehuetenango (46.5%). In contrast, 96% of all children 6–23 months
old met the minimum meal frequency as defined by WHO indicators.39 Among non-breastfed children,
diets were of particular concern given that none of the children surveyed were being fed according to
WHO’s minimum feeding practice standards.
37 The Demographic and Health Surveys supported by ICF Macro measure BMI in women 15–49 years of age who are 3 months or more postpartum. That is, BMI is not measured in pregnant women or women within 2 months postpartum. 38 The WHO report on indicators for assessing IYCF practices defines minimum dietary diversity as the proportion of children between 6 and 23 months old who receive foods from four or more groups. 39 Minimum meal frequency is defined as the proportion of breastfed and non-breastfed children 6–23 months of age who receive
solid, semi-solid, or soft foods (but also including milk feeds for non-breastfed children) the minimum number of two times per
day for breastfed infants 6–8 months old, 3 times for breastfed infants 9–23 months old, and 4 times for non-breastfed children 6–23 months old.
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Table 16. Nutritional Status of Non-Pregnant Women (Including Lactating Women)
Age (years)
BMI
Huehuetenango Quiché
N Percentage
< 18.5
Percentage ≥ 18.5 and
< 25.0
Percentage ≥ 25.0 and
< 30.0 Percentage
≥ 30.0 N Percentage
< 18.5
Percentage ≥ 18.5 and
< 25.0
Percentage ≥ 25.0 and
< 30.0 Percentage
≥ 30.0
16–19 18 5.6 83.3 11.1 0.0 15 0.0 73.3 26.7 0.0
20–24 25 4.0 64.0 28.0 4.0 22 4.6 77.2 18.2 0.0
25–29 23 0.0 52.2 34.8 13.0 23 4.4 65.2 17.4 13.0
30–34 13 0.0 61.5 30.8 7.7 23 0.0 60.8 34.8 4.4
35–39 10 0.0 70.0 30.0 0.0 16 12.5 56.2 31.3 0.0
40–44 4 0.0 75.0 25.0 0.0 6 16.7 66.6 16.7 0.0
Total 93 1.6 67.7 26.6 4.1 105 6.4 66.6 24.2 2.9
Note: BMI classifications: Underweight (BMI < 18.5), normal (BMI ≥ 18.5 to < 25.0), overweight (BMI ≥ 25.0 to < 30.0), and obese (BMI ≥ 30.0)
Table 17. Infant and Young Child Feeding Practices
Background characteristic
Among breastfed children 6–23 months, percentage fed:
Number of breastfed
children 6–23 months
Among non-breastfed children 6–23 months, percentage fed: Number of
non-breastfed
children 6–23 months
Among all children 6–23 months, percentage fed: Number
of children
6–23 months
4+ food groupsa
Minimum meal
frequencyb
Both 4+ food groups and
minimum meal frequency
Milk or milk productsc
4+ food groupsa
Minimum meal
frequencyd With 3 IYCF practicese
Breast milk, or milk
productsf 4+ food groupsa
Minimum meal
frequencyg
With 3 IYCF
practices
Age (months)
6–8 36.0 97.3 36.0 111 0.0 33.3 100.0 0.0 3 97.4 36.0 98.2 35.1 114 9–11 50.6 95.2 50.6 83 0.0 20.0 80.0 0.0 5 94.3 48.9 94.3 47.7 88 12–23 47.2 98.6 47.2 142 25.0 6.3 89.6 0.0 48 74.7 36.8 96.3 35.3 190 Sex Male 43.2 96.1 43.2 155 0.0 15.2 84.9 0.0 33 82.5 38.3 94.2 35.6 188 Female 44.9 98.3 44.9 178 0.0 0.0 95.7 0.0 23 88.6 39.8 98.0 39.8 201 Department
Huehuetenango 53.6 97.6 53.6 168 0.0 6.7 83.3 0.0 30 84.9 46.5 95.5 45.5 195 Quiché 35.1 97.0 35.1 168 0.0 12.0 96.0 0.0 25 87.1 32.1 96.9 30.6 183 Total 44.1 97.3 44.4 336 3.6 9.1 89.1 0.0 56 85.7 39.3 96.2 38.0 392
a Food groups: infant formula, milk other than breast milk, cheese, or yogurt or other milk products; foods made from grains, roots, and tubers, including porridge and fortified baby food from
grains; vitamin A-rich fruits and vegetables; other fruits and vegetables; eggs; meat, poultry, fish, and shellfish (and organ meats); legumes and nuts. b For breastfed children, minimum meal frequency is receiving solid, semi-solid, or soft food at least twice a day for children 6–8 months and at least three times a day for children 9–23 months. c Includes two or more feedings of commercial infant formula; fresh, tinned, and powdered animal milk; and yogurt. d For non-breastfed children 6–23 months old, minimum meal frequency is receiving solid, semi-solid, or soft food or milk feeds at least four times a day. e Non-breastfed children 6–23 months old are considered to be fed with a minimum standard of three IYCF practices if they receive other milk or milk products at least twice a day, receive the
minimum meal frequency, and receive solid, semi-solid, or soft foods from at least four food groups not including the milk/milk product group. f Breastfeeding, or not breastfeeding and receiving two or more feedings of commercial infant formula; fresh, tinned, and powdered animal milk; and yogurt. g Children are fed the minimum recommended number of times per day according to their age and breastfeeding status as described in notes b and d.
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3.1.6 Most Frequently Reported Foods
The types of foods consumed by all the target groups and in both departments were very similar (see
Appendix 2 and Appendix 3). The 10 most frequently consumed foods were maize products, sugar, salt,
tomatoes, onions, coffee, black beans, potatoes, dehydrated soup mix, and eggs (for children 12–23
months old). Enriched and fortified foods (e.g., pasta, fortified instant oats, and Incaparina) and GLVs
(e.g., nightshade [hierba mora {Solanum tuberosum}] and amaranth leaves) were reported less frequently.
Animal-source foods, except for eggs, were almost completely absent from the diets. Maize consumption
was found to be very high in both departments. However, there are differences in the types of maize
consumed and their preparation. In Quiché, more women consumed yellow corn (instead of white) and
tamalitos (instead of tortillas). More women in Quiché than in Huehuetenango also reported consuming
hot chili.
Processed foods with low nutrient value are shown in Table 18. Few “junk foods” were consumed by the
women and children surveyed, except for sweetened beverages, which were consumed by 13.5% of
women and children.
Table 18. Consumption of Processed Food with Low Nutritional Value by Children 6–23 Months Old and Women
Food % of children consuming food % of women consuming food
Dehydrated soup mix, chicken noodle or ramen noodle
48.4 45.8
Dry broth cubes, chicken or beef 32.6 35.5
Sweetened beverages (carbonated or from concentrate)
10.2 18.7
Cookies 6.8 –
3.1.7 Main Food Sources of Nutrients
The main food sources of energy, protein, iron, zinc, calcium, vitamin A, and folate are shown in
Appendix 4 and Appendix 5. For all target groups, maize products and sugar (fortified with vitamin A
and iron) are the major sources of energy, contributing almost half of the energy in the diets of children
and two-thirds of the energy in the diets of women. Due to the quantity of maize products consumed, this
category of foods also contributes much of the protein, iron, zinc, calcium, and folate in the diets of all the
target groups. Similarly, since sugar is fortified with vitamin A, sugar is the main source of vitamin A.
Although sugar consumed in the Western Highlands is also fortified with iron,40 sugar is not a major
source of iron in the diet, which could be a result of the level of fortification (0.9 mg/100 g). In addition to
maize and sugar, Incaparina, black beans, potatoes, eggs, and bread provide the majority of nutrients,
emphasizing the lack of dietary diversity and low intake of animal-source foods. The majority of protein
in the diets of women and children was provided by non-animal food sources, mainly maize, as well as
potatoes, black beans, and Incaparina (for children). Eggs provided between 7.5% and 11.3% of dietary
protein for children and from 3.9% to 6.0% of protein for pregnant and lactating women (Appendix 4 and
Appendix 5).
40 By law, all sugar in Guatemala is fortified with vitamin A. In some areas of the country, double-fortified sugar with both vitamin A and iron is available; however, fortification with iron is currently not mandatory.
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3.1.8 Nutrient Intake and Adequacy
Analysis of adequacy of nutrient intake was based on the INCAP FCT (INCAP 2007) and the INCAP
Daily Dietary Recommendations (INCAP 2012). The purpose of the cross-sectional survey was to
identify the dietary patterns of the target groups as a basis for analysis in Optifood. To identify the dietary
patterns, only one 24-hour recall was required. However, to determine the usual distribution of nutrient
intake of a group of individuals to assess the proportion who are at risk of inadequate intakes, it is
necessary to conduct at least two 24-hour recalls from each person on nonconsecutive days to avoid
overestimates of nutrient inadequacy or to use an analysis of variance based on second 24-hour recalls
from a subset of participants to adjust the distribution of observed intake (Otten et al. 2006; Gibson and
Ferguson 2008). Given that only one 24-hour recall was obtained for all participants through the cross-
sectional survey, it was not possible to report on the proportions of individuals within the target groups at
risk of inadequate intakes. The distributions of nutrient intake are shown in Appendices 6–11.
Despite the limitation of only one 24-hour recall, it is notable that the amount of energy and protein intake
for all child target groups in both departments was in the range of being adequate (Table 19). In contrast,
the mean estimated energy and protein intake for women in both departments was low compared to the
estimated requirements for pregnant and lactating women. However, the SD was large, so it is difficult to
know if actual intakes were low. Table 20 shows the estimated energy and protein intake for pregnant and
lactating women based on the 24-hour recall data.
Although the quantity of protein intake among children surveyed seemed sufficient, the quality of protein
may be inadequate considering that the majority of protein in the diet was from maize. Very few animal-
source foods were consumed and both grains and legumes were often not consumed together. Further
details on protein consumption are discussed below.
Figure 6 provides information on the average iron and zinc densities of children’s complementary foods,
compared to desired densities for iron and zinc. The average iron densities of the complementary foods
consumed by breastfed children 6–8, 9–11, and 12–23 months were 1.1 mg/100 kcal, 1.1 mg/100 kcal,
and 1.2 mg/100 kcal, respectively. The average desired iron density values are 4.5 mg/100 kcal,
3.0 mg/100 kcal, and 1.0 mg/100 kcal for breastfed children 6–8, 9–11, and 12–23 months, respectively
(Dewey and Brown 2003). These results suggest that the iron content in the diet is suboptimal for
breastfed children 6–11 months.
The average zinc densities of the complementary foods consumed by breastfed children 6–8, 9–11, and
12–23 months were the same, 0.5 mg/100 kcal. The average desired zinc density values are 1.6, 1.1, and
0.6 mg/100 kcal for breastfed children 6–8, 9–11, and 12–23 months, respectively (Dewey and Brown
2003). These results suggest that the zinc content in the diet is also suboptimal for breastfed children 6–11
months.
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Table 19. Energy and Protein Intake from Complementary Food for Children 6–23 Months
Estimated energy requirement from
complementary food based on moderate
activity level (kcal)a,b Huehuetenango Mean kcal (SD)
Quiché Mean kcal (SD)
Estimated protein requirement from
complementary food (g)c
Huehuetenango Mean g (SD)
Quiché Mean g (SD)
Breastfed children 6–8 months ≈ 200 346 (220) 268 (209) ≈ 2 11 (7) 7 (6)
Breastfed children 9–11 months ≈ 300 430 (209) 385 (237) ≈ 3 13 (7) 11 (7)
Breastfed children 12–23 months ≈ 550 578 (367) 612 (313) ≈ 5 19 (11) 18 (10)
Non-breastfed children 12–23 months
≈ 900 924 (546) 1,048 (515) ≈ 16 26 (13) 31 (19)
a PAHO/WHO. 2003. b WHO. 2005. c WHO/UNICEF. 1998.
Table 20. Energy and Protein Intake for Pregnant and Lactating Women
Estimated energy requirement based
on moderate activity level (kcal)a
Huehuetenango Mean kcal (SD)
Quiché Mean kcal (SD)
Estimated protein
requirement (g) Huehuetenango
Mean g (SD) Quiché
Mean g (SD)
Pregnant women ≈ 2,700 2,178 (792) 2,255 (993) ≈ 80 68 (29) 68 (37)
Lactating women ≈ 2,900 2,243 (838) 2,730b (835) ≈ 85 71 (33) 77 (22)
a INCAP. 2012. b Mean comparison between departments, p < 0.05.
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Figure 6. Average Iron and Zinc Densities of Children's Complementary Foods and Recommended Densities
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
6–8 months 9–11 months 12–23 months
Iron
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
6–8 months 9–11 months 12–23 months
Zinc
3.1.9 Protein Consumption
Children
Based on the nutrient density of the complementary food consumed, the average protein density in the
diet was 2.9, 2.9, and 3.1 for children 6–8 months, 9–11 months, and 12–23 months, respectively.
According to the reference authority used (WHO/FAO/UNU 2007), the average desired values are 1.0,
1.0, and 0.9 for each respective target group, which suggests that the protein content in the diets of each
of the child age groups is adequate. Further, the values observed in this study group were higher than
those previously reported for Guatemalan children by Dewey and Brown (2003). Despite this, the nutrient
density approach to evaluate protein intake does not take into account the quality of the protein
consumed. Although protein intake from complementary foods for all child target groups in both
departments was in the “adequate” range, the quality of protein may be inadequate considering that the
majority of the protein in the diet was from maize and that very few animal-source foods were consumed.
Additionally, grains and legumes were not often consumed together, an important distinction, as this
combination provides the essential amino acids for a complete protein. However, analysis of essential
amino acids in the diet was beyond the scope of this activity. Building on Appendix 4, the presence of
animal foods as a protein source in the diets of young children was as follows.
Breastfed children 6–8 months. Within the top 16 foods comprising 80.5% of the protein
contribution, chicken eggs were the only animal product, representing about 7.5% of protein
contribution.
Breastfed children 9–11 months. Within the top 15 foods, which make up 80% of the protein
contribution, only chicken eggs (top 3, representing 7.8% of protein contribution) and cow’s milk
(top 14) were animal products.
Breastfed children 12–23 months. Within the top 15 foods, which make up 80% of the protein
contribution, only chicken eggs, beef, and cow’s milk corresponded to an animal product, which
combined represented about 15% of protein contribution.
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Non-breastfed children 12–23 months. Within the top 14 foods, which make up 80% of the
protein contribution, only three foods—chicken eggs (top 2), cow’s milk (top 10), and beef
(top 12)—corresponded to an animal product, which combined represented about 15% of protein
contribution.
Women
The mean ± SD (median) protein intake in pregnant women was 68.2 ± 28.9 (69.0) g for Huehuetenango
and 67.8 ± 37.3 (58.7) g for Quiché, meeting about 78% and 66% of required adequacy for each area,
respectively (Table 20). The mean ± SD (median) intake in lactating women was 70.8 ± 33.4 (66.9) g and
77.0 ± 22.4 (75.6) g for Huehuetenango and Quiché, respectively, with adequacies of 98% and 80%,
respectively (Table 20). Protein intake is comparable among pregnant and lactating women in
Huehuetenango, but in Quiché, lactating women have a higher intake than pregnant women. However, for
all groups, the mean intake is relatively low and there was notable variation between respondents. These
findings suggest that different patterns may exist in the dietary intake of women during the reproductive
cycle in these two neighboring departments, with lactating women from Huehuetenango facing the
highest risk of protein deficiency. The top five foods sources of protein for pregnant and lactating women
are presented in Appendix 5. The presence of animal food in the diets of these target groups was as
follows:
For pregnant women, within the top nine foods, which make up 80% of the protein contribution,
only chicken eggs (top 3), chicken (top 6), and beef (top 9) corresponded to an animal product,
which combined represented about 7.5% of protein contribution.
For lactating women, within the top 5 foods, which make up 80% of the protein contribution, only
chicken eggs (top 3) and chicken (top 6) corresponded to an animal product, which combined
represented about 7.3% of protein contribution.
Overall, the protein intake of pregnant and lactating women is suboptimal, and therefore presents a risk of
protein deficiency. In addition, it is important to highlight the quality of the protein in the diet given the
predominance of plant-based sources in this population, in which maize is the main source, accompanied
by limited animal food.
3.2 Results from Step 2: Analysis using Optifood
3.2.1 Weekly Food Group Servings Needed to Optimize Nutritional Content of Diets
The numbers of servings of foods from each food group selected in the two best diets as per the results in
Module 2 are shown in Table 21. The food pattern goal in each model (i.e., observed medians) is shown
in parenthesis for each food group and target group. These results show that to optimize the nutritional
content of local diets there was an increase in the numbers of servings of vegetables for all target groups
from 2 or 3 servings/day of vegetables to 3 or 5 servings/day, depending on the target group. The
observed median intakes of dairy products were low in all target groups (< 1 serving/week) and were
increased to 1 serving per day in the optimized diets of most target groups. Other food groups that showed
an increase in the number of servings per week from the observed median intakes were meat, poultry, or
eggs (MPE) (4 target groups), fruits (3 target groups), legumes (3 target groups), and roots (2 target
groups). Bakery products and composites increased in the optimized diets of non-breastfed children and
adults, presumably to increase the dietary fat content to meet the fat recommendations. For legumes in
adult diets and root vegetables in young child diets, their observed intakes were already at or close to once
per day, so the absence of an increase with diet optimization was not surprising. Of interest was the
decrease in the number of servings of fortified sugar selected in the optimized diets for all target groups to
the lowest constraint levels possible.
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Table 21. Range in Food Group Patterns (servings/week) Selected for the Two Best Diets from Module 2 and Modeled Food Group Pattern (individual servings/week) Goalsa
Food Pattern
Breastfed 6–8 months Breastfed 9–11 months Breastfed
12–23 months Non-breastfed 12–23 months Pregnant Lactating
Diet Ac
servings/w
Diet Bd
servings/w
Diet Ac
servings/w
Diet Bd
servings/w
Diet Ac
servings/w
Diet Bd
servings/w
Diet Ac
servings/w
Diet Bd
servings/w
Diet Ac
servings/w
Diet Bd
servings/w
Diet Ac
servings/w
Diet Bd
servings/w
Added sugars
Added fats
Fruits
Vegetables
Dairy products
Legumes
MPE
Roots
Grains and grain products
Bakery, breakfast cereal
Beverages
Composites
6 (6)
0 (0)b
1 (0)b
14 (14)
7 (0)b
7 (0)b
2 (0)b
6 (6)
28 (28)
0 (0)b
7 (7)
7 (7)
3
0
1
28
7
7
2
6
29
0
0
0
7 (7)
0 (0)b
0 (0)b
14 (14)
7 (0)b
7 (0)b
6 (0)b
7 (0)b
28 (28)
0 (0)b
7 (7)
7 (7)
5
0
0
23
7
7
5
4
35
0
0
4
7 (7)
0 (0)b
4 (4)
14 (14)
6 (0)b
7 (0)b
5 (0)b
0 (0)b
28 (28)
0 (0)b
7 (7)
7 (7)
5
0
7
24
2
7
7
3
35
0
7
0
7 (7)
3 (6)
7 (0)b
21 (21)
7 (0)b
0 (0)b
6 (7)
4 (4)
35 (35)
6 (0)b
7 (7)
11 (11)
5
3
7
35
7
0
6
0
30
7
7
14
7 (7)
4 (0)b
4 (4)
21 (21)
7 (0)b
7 (7)
4 (4)
7 (7)
28 (28)
7 (0)b
7 (7)
7 (7)
5
4
8
27
7
8
8
7
40
7
7
12
7 (7)
5 (0)b
0 (0)b
21 (21)
6 (0)b
7 (7)
7 (7)
7 (0)b
35 (35)
7 (0)b
7 (7)
7 (7)
5
5
0
28
6
7
8
0
39
7
7
14
a The ‘average’ food pattern (median or 50th percentile) in each model is shown in parenthesis. b The goal entered into Optifood was 1 instead of the observed value of 0 for mathematical reasons. However, these goals were not active in the models. c Diet A is a diet that comes as close as possible to achieving the target population’s RDAs for selected nutrients while adhering to the set dietary patterns as much as possible (defined by the 50th
percentile or median consumption for food groups). d Diet B is a diet that comes as close as possible to meeting the target population’s RDAs, without taking dietary patterns (median consumption of food groups) into account.
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3.2.2 Food Sources of Nutrients
The foods providing 5% or more of nutrients in best Diet B, the diet optimized to meet only nutrient
requirements without considering dietary patterns, are shown in Table 22. These results show that 35 of
the 61 modeled foods were good sources of at least one nutrient. Of these 35 foods, 11 were selected 10
or more times as a good source of a nutrient for a target group and 6 were selected for 7 or more nutrients
(range of 7–9 nutrients). These 11 foods were41:
Incaparina (39 times; 9 nutrients)
Tortilla from yellow corn (31 times; 7 nutrients)
Tamalito from yellow/white corn (25 times; 7 nutrients)
Nightshade leaves (hierba mora [Solanum tuberosum]) (21 times; 8 nutrients)
Amaranth leaves (21 times; 8 nutrients)
Oats, instant, fortified (14 times; 7 nutrients)
Black beans, mature (12 times; 5 nutrients)
Potatoes (11 times; 3 nutrients)
Chayote fruit (Sechium edule) (10 times; 3 nutrients)
Eggs, whole (10 times; 3 nutrients)
Pumpkin, yellow (10 times; 3 nutrients)
41 The list shows “food source (# of times selected as a good source of a nutrient for a target group; # of nutrients for which it is a good source).”
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Table 22. Foods Providing > 5% of the Total Micronutrient Content of the Optifood Diet That Met or Came as Close as Possible to Meeting Nutrient Needs
Calcium Iron Zinc Vitamin C Vitamin A Vitamin B12
Tortilla, or other maize products
Incaparina Amaranth leaves Nightshade leaves* Milk, powder Cabbage Chipilin leaves** Cheese
Tortilla, or other maize products
Incaparina Amaranth leaves Nightshade leaves* Black beans Bread, sweet Oats, instant, fortified
Tortilla, or other maize products
Incaparina Black beans Amaranth leaves Chayote/guisquil
fruit***
Chayote/guisquil fruit*** Potatoes Pumpkin, yellow Amaranth leaves Nightshade leaves* Cabbage Chipilin leaves** Beans, snap green Tomato, red Tomato tree Onions, bulbs and tops Oranges, sweet
Sugar, fortified Amaranth leaves Pumpkin, yellow Nightshade leaves* Carrots Oats, instant, fortified Chipilin leaves** Turnip greens Eggs, whole Liver Incaparina
Incaparina Milk, powder Eggs, whole Chicken, meat and skin Lamb, meat Frankfurter, beef and
pork Liver
Thiamin Riboflavin Niacin Folate Vitamin B6
Tortilla, or other maize products
Incaparina Oats, instant, fortified Black beans Nightshade leaves* Broth, beans Pasta, enriched Oranges, sweet
Eggs, whole Incaparina Milk, powder Oats, instant, fortified Amaranth leaves Tortilla, or other maize
products Nightshade leaves* Bread, sweet Chipilin leaves** Liver Pasta, enriched
Tortilla, or other maize products
Incaparina Potatoes Oats, instant, fortified Chicken, meat and
skin Liver Pasta, enriched Oats, not fortified
Incaparina Chayote/guisquil fruit*** Black beans Oats, instant, fortified Amaranth leaves Nightshade leaves* Pumpkin, yellow Oranges, sweet Cabbage Beans, snap
green Broth, beans Corn grains, yellow Pasta, enriched
Tortilla, or other maize products
Potatoes Black beans Nightshade leaves* Oats, instant, fortified Amaranth leaves Cabbage Crotalaria leaves Chayote/guisquil
fruit*** Chayote/guisquil shoots
and leaves***
* Hierba mora (Solanum tuberosum). Note: This should not be eaten when the plant is producing seeds.
** Crotalaria longirostrata.
*** Sechium edule.
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The top three food sources and food subgroup sources for each nutrient and target group are presented in
Table 23 and Table 24. These results, combined with the optimized nutrient levels in the best Diets A
and B and the worst-case scenario results, helped guide the selection of FBRs to test in Module 3. These
results show that the important food and food subgroup sources of each nutrient were relatively consistent
across all target groups. As a subgroup, whole corn (maize) products such as tortillas or tamalitos were an
important source of minerals, thiamin, niacin, and vitamin B6. However, due to the higher nutrient value,
yellow corn was consistently selected by Optifood instead of products made from white corn.
Nevertheless, yellow corn was not selected for further analysis because INCAP researchers deemed that it
was unrealistic that people in the target communities would change their maize crops. Atoles, which
included Incaparina and fortified instant oats, were within the top three food sources for all nutrients
except for vitamin C. Vegetables, especially GLVs, were also important sources of most nutrients, and,
depending on the target group, black beans were an important source of folate, thiamin, B6, iron, and
zinc. MPE was an important source of B12, riboflavin, and fat. Of the GLVs, amaranth leaves and
nightshade leaves (hierba mora [Solanum tuberosum]) were the best sources of nutrients and, from the
vegetables, it was chayote (Sechium edule). Potatoes were an important source of B6. In contrast, fruits
were not a main source of nutrients, even for vitamin C, in four of the six target groups’ best Diet B.
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Table 23. Top Three FOOD SUBGROUP Sources (excluding breast milk) in Ranked Order, of Micronutrients and Fat in the Best Diet That Does Not Take Dietary Patterns into Account (Diet B from Module 2)
Calcium Iron Zinc Vitamin C Vitamin A B12 B1 B2 B3 B6 Folate Fat
Breastfed 6–8 months
Whole grain
GLVs Atoles
Atoles GLVs Whole grain
Atoles Whole grain Other veg
GLVs Other veg Roots
Atoles GLVs Vit A veg
Atoles Eggs Milk
Atoles Whole grain GLVs
Atoles GLVs Eggs
Atoles Whole grain Roots
Roots Whole grain Atoles
Atoles Beans Other veg
Eggs Atoles Milk
Breastfed 9–11 months
GLVs Whole
grain Atoles
GLVs Atoles Whole
grain
Atoles Whole
grain GLVs
GLVs Other veg Vit C veg
GLVs Fort’d
sugar Atoles
Atoles GLVs Eggs
Atoles Whole
grain GLVs
Atoles GLVs Egg
Atoles Whole
grain GLVs
Whole grain
GLVs Roots
Atoles Beans GLVs
Eggs Atoles Milk
Breastfed 12–23 months
Whole grain
Atoles GLVs
Atoles GLVs Whole
grain
Atoles Whole
grain Beans
GLVs Other veg Vit C veg
Atoles GLVs Sugar
Eggs Atoles Milk
Atoles Whole
grain Beans
Atoles Eggs GLVs
Atoles Whole
grain Beans
Whole grain
Atoles GLVs
Atoles Beans Other veg
Egg Atoles Whole
grain
Non-breastfed 12–23 months
Whole grain
Atoles GLVs
Atoles Whole
grain GLVs
Atoles Whole
grain Bread
Vit C veg GLVs Other veg
Sugar Atoles GLV
Eggs Atoles Milk
Atoles Whole
grain Bread
Atoles Egg Bread
Atoles Whole
grain Poultry
Whole grain
GLVs Vit C veg
Atoles Vit C veg Bread
Bread Eggs Whole
grain
Pregnant women
Whole grain
GLVs Atoles
Whole grain
Atoles Beans
Whole grain
Atoles Beans
Vit C fruit GLVs Other veg
GLVs Vit A veg Sugar
Eggs Proc’d
meat Red meat
Whole grain
Atoles Enrich grain
Atoles Whole
grain Eggs
Atoles Whole
grain Poultry
Whole grain
Roots Beans
Beans Atoles GLVs
Poultry Proc’d
meat Whole
grain
Lactating women
Whole grain
GLVs Cheese
Whole grain
Atoles GLVs
Whole grain
Atoles GLVs
GLVs Vit A veg Vit C veg
Organ meat GLVs Vit A veg
Organ meat Eggs Atoles
Whole grain
Atoles Beans
Atoles Whole
grain Organ meat
Whole grain
Atoles Poultry
Whole grain
GLVs Beans
Beans Other veg Atoles
Whole grain
Poultry Bread
Veg = vegetables; Vit = vitamin; Fort’d = fortified; Proc’d = processed; atoles included Incaparina and fortified instant oats
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Table 24. Top Three FOOD Sources (excluding breast milk) in Ranked Order of Fat and Micronutrients in the Best Diet That Does Not Take Dietary Patterns into Account (Diet B from Module 2)
Calcium Iron Zinc Vitamin C Vitamin A B12 B1 B2 B3 B6 Folate Fat
Breastfed 6–8 months old
Tortilla, Y Nightsh. lvs Tamalito
Fort’d oats Nightsh. lvs Incaparina
Incaparina Tortilla, Y Tamalito
Nightsh. lvs Chayote Potato
Fort’d oats Carrots Nightsh. lvs
Incaparina Eggs Milk
Incaparina Fort’d oats Tortilla, Y
Incaparina Fort’d oats Nightsh. lvs
Incaparina Fort’d oats Tamalito
Potatoes Fort’d oats Nightsh. lvs
Chayote Black beans Incaparina
Eggs Incaparina Milk
Breastfed 9–11 months old
Tortilla, Y Amaranth
lvs Nightsh. lvs
Nightsh. lvs Incaparina Amaranth
lvs
Incaparina Tortilla, Y Amaranth
lvs
Nightsh. lvs Amaranth
lvs Chayote
Amaranth lvs
Fort’d sugar Nightsh. lvs
Eggs Incaparina Milk
Incaparina Tortilla, Y Fort’d oats
Incaparina Eggs Nightsh. lvs
Incaparina Fort’d oats Tortilla, Y
Potatoes Tortilla, Y Nightsh. lvs
Incaparina Chayote Black beans
Eggs Milk Incaparina
Breastfed 12–23 months old
Tortilla, Y Incaparina Black beans
Incaparina Fort’d oats Black beans
Incaparina Black beans Eggs
Nightsh. lvs Chayote Crotalaria
lvs
Fort’d oats Fort’d sugar Eggs
Eggs Incaparina Milk
Incaparina Fort’d oats Black beans
Incaparina Eggs Fort’d oats
Incaparina Fort’d oats Tamalito
Fort’d oats Tortilla, Y Black beans
Black beans Incaparina Chayote
Eggs Incaparina Tortilla, Y
Non-breastfed 12–23 months old
Tamalito Tortilla, Y Incaparina
Incaparina Nightsh. lvs Bread
Incaparina Tamalito Tortilla
Cabbage Nightsh. lvs Beans, snap
Fort’d sugar Nightsh. lvs Incaparina
Eggs Incaparina Milk
Incaparina Tamalito Tortilla, Y
Incaparina Eggs Bread
Incaparina Tamalito Tortilla, Y
Tamalito Tortilla, Y Nightsh. lvs
Incaparina Cabbage Bread
Bread Eggs Tamalito
Pregnant women
Tortilla, Y Tamalito Amaranth
lvs
Tortilla, Y Tamalito Incaparina
Incaparina Tortilla, Y Tamalito
Oranges Amaranth
lvs Chayote
Lamb liver Fort’d sugar Amaranth
lvs
Lamb liver Eggs Frankfurter
Incaparina Tortilla, Y Pasta
Incaparina Liver, lamb Egg
Incaparina Tamalito Chicken
Tortilla, Y Tamalito Potatoes
Black Beans Chayote Incaparina
Chicken Frankfurter Bread
Lactating women
Tortilla, Y Tamalito Amaranth
lvs
Tortilla, Y Tamalito Amaranth
lvs Incaparina
Tortilla, Y Tamalito Incaparina
Amaranth lvs
Pumpkin Chayote
Lamb liver Amaranth
lvs Pumpkin
Lamb liver Eggs Incaparina
Tortilla, Y Incaparina Tamalito
Incaparina Liver, lamb Tortilla, Y
Tamalito Incaparina Tortilla, Y
Tortilla, Y Tamalito Amaranth
lvs
Black Beans Chayote Amaranth
lvs
Chicken Tamalito Bread
Y = yellow corn; Fort’d = fortified; lvs = leaves; Nightsh. = Nightshade
Notes: Nightshade (hierba mora [Solanum tuberosum]. Note: This should not be eaten when the plant is producing seeds.)
Chipilin (Crotalaria longirostrata)
Chayote (Sechium edule)
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3.3.3 Problem Nutrients
The problem nutrients were explored for diets with and without Incaparina and fortified instant oats and
using dietary reference values from different authorities:
INCAP RDAs42 (standard dietary reference used in this analysis)
iZiNCg RDAs
FAO/WHO RNIs
IOM RDAs for iron for pregnant and lactating women
Using the iZiNCg RDAs for zinc did not change the results of the analysis when compared with the
INCAP RDAs. Differences using the dietary reference values for FAO/WHO, INCAP, and IOM for iron
for pregnant and lactating women are shown in Table 25 (page 53).
Breastfed Children 6–8 Months Old
The results showed that for breastfed children 6–8 months calcium, iron, and zinc were consistent
problem nutrients, suggesting that local food sources will not ensure their needs for these three nutrients
will be met. Their requirements for niacin would also not be met if Incaparina and fortified instant oats
were excluded from the diets. The results showed identical problem nutrients for children 6–8 months old
regardless of the dietary references used.
Breastfed Children 9–11 Months Old
For breastfed children 9–11 months old, zinc was the only problem nutrient. Iron also was a problem
nutrient when the FAO/WHO RNI that assumes low bioavailability, 18.6 mg/day, was used. The INCAP
Daily Dietary Recommendations assume that the diets of children 9–11 months old are of moderate
bioavailability and therefore no separate RDA is given for low bioavailability. The FAO/WHO RNI
assuming moderate bioavailability, 9.3 mg/day, is similar to the INCAP RDA of 9 mg/day. Therefore,
iron is a problem nutrient only when the FAO/WHO RNI assuming low bioavailability is used. A further
analysis for all dietary references was run that excluded Incaparina and fortified instant oats from the diets
with results showing that iron would also be a problem nutrient for this age group, using all dietary
references if these foods were not available/eaten.
Breastfed Children 12–23 Months Old
For breastfed children 12–23 months old, iron was a problem nutrient using the INCAP dietary
references. Zinc, calcium, and niacin became problem nutrients when Incaparina and fortified instant oats
were excluded from the modeled diets. However, calcium and niacin were only partial problem nutrients,
indicating that local food sources could supply adequate amounts of these nutrients but that this would be
to the detriment of other nutrients (meaning other nutrients would not be able to be accessed in the same
levels). Iron was not a problem nutrient for this age group when the FAO/WHO RNIs were used. The
FAO/WHO RNI for iron, assuming low bioavailability, is 11.6 mg/day, compared with 14 mg/day for the
INCAP RDA, assuming low bioavailability. With regard to zinc, the opposite situation occurs: It is a
problem nutrient when using the FAO/WHO RNIs but not when using the INCAP RDAs.
42 The INCAP RDAs were developed by an expert panel at INCAP. They were based on RNIs/RDAs from different authorities, including FAO/WHO RNIs, with adjustments for bioavailability
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Non-Breastfed Children 12–23 Months Old
For the non-breastfed children, only fat was a consistent problem nutrient in the modeled diets. Breast
milk is an important source of fat for this age group. Iron was a problem nutrient for non-breastfed
children 12–23 months old when Incaparina and fortified instant oats were not included in the diets. Iron
was not a problem nutrient for this age group when the FAO/WHO RNIs were used. The FAO/WHO RNI
for iron, assuming low bioavailability, is 11.6 mg/day, compared with 14 mg/day for the INCAP RDA,
assuming low bioavailability.
Pregnant Women
For pregnant women, fat was low in all modeled diets, indicating it was difficult to select a diet that
provided 30% of energy from fat. Folate and zinc were partial problem nutrients for pregnant women,
indicating that local food sources could supply adequate amounts of these nutrients but that this would be
to the detriment of other nutrients (meaning that people would have to eat such large amounts of the folate
and zinc-rich foods that it would displace foods providing the other nutrients). Vitamin B12 would have
been a problem nutrient if liver was not included in the food lists. When Incaparina and fortified instant
oats were excluded from the models, folate and zinc became problem nutrients (Table 29).
FAO/WHO and INCAP do not provide values for dietary iron requirements in pregnant women because
iron intake from food is generally not sufficient to meet nutrient requirements during pregnancy. Analysis
using an estimated RDA value (81.3 mg/day) based on the IOM RDA for pregnant women in the third
trimester value, and adjusted proportionally for 5% bioavailability of iron in the diet, confirmed that iron
is a problem nutrient for pregnant women if only local foods are consumed (without supplementation).
The iron balance in pregnancy depends on the properties of the diet and the amounts of stored iron. In
Guatemala, the prevalence of anemia, defined as < 11.0 g/dL for pregnant women and < 12.0 g/dLfor
non-pregnant women over 15 years old (World Health Organisation 2001), among non-pregnant women
is 21% and among pregnant women is 29% (MSPAS/INE/CDC 2010). The low bioavailability of iron in
the diet and probability of a high prevalence of low iron stores make it unlikely that pregnant women in
Guatemala can meet their daily requirements for iron. As a result, MSPAS recommends the consumption
of 600 mg once per week of ferrous sulfate and 5 mg of folic acid once per week for pregnant women
(MSPAS 2004). As INCAP does not provide an RDA for iron for pregnant woman, the INCAP RDA for
iron for lactating woman was used for the purpose of modeling the FBRs.
Lactating Women
For lactating women, micronutrients were not problem nutrients unless Incaparina and fortified instant
oats were excluded from the food list (Table 29). Fat was low in all modeled diets, indicating it was
difficult to select a diet that provided 30% of energy from fat. Vitamin B12 would be a problem nutrient if
liver was not included in the food lists. When Incaparina and fortified instant oats were excluded from the
models, zinc became a problem nutrient, but iron did not. However, iron was a problem nutrient when the
IOM RDA for lactating women, adjusted proportionally for 5% bioavailability, was used. The adjusted
IOM RDA is 58.8 mg/day as compared with 31.2 mg/day for the INCAP RDA.
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Table 25. Problem Nutrients
Modeled diets included: Problem Nutrients
Dietary reference authority
Incaparina and fortified instant oats
(yes/no) Liver (yes/no) Breastfed
6–8 months old Breastfed
9–11 months old Breastfed
12–23 months old Non-breastfed
12–23 months old Pregnant Lactating
INCAP Yes No Iron Zinc
Calcium
Zinc Iron
Fat Iron Zinc
Folate B12 Fat
B12 Fat
No No Iron Zinc
Calcium Niacin
Iron Zinc
Iron Zinc
Calcium Niacin
Iron Fat
Iron Zinc
Folate B12 Fat
Zinc B12 Fat
Yes Yes – – – – Iron Zinc
Folate Fat
Fat
FAO/WHO, except for iron for pregnant and lactating women, which were based on IOM
Yes No Iron Zinc
Calcium
Iron Zinc
Zinc Fat Iron Folate
Fat
Iron Fat
Note: Nutrients in italics are partial problem nutrients, defined as those whose best-case scenario levels met or exceeded their RDAs, but whose levels in the Module 2 Best
Diets were below their RDAs, meaning that meeting the RDAs would likely be detrimental for other nutrients given local food patterns.
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3.3.4 Food-Based Recommendations
In formulating the FBRs for all target groups, only micronutrients were taken into account. Even though
fat was a problem nutrient for women and non-breastfed children, dietary requirements are not well
established and it is difficult to develop recommendations for fat intake.
Stage 1 of the analyses in Module 3, which derived the set of individual FBRs to evaluate further in
Stages 2 and 3, is presented in Appendices 16–21. Stages 2–3 of the analyses, which were used to justify
the selection of the final set of FBRs, are shown in Appendices 22–27. In these sets of analyses, all
permutations of the seven final individual FBRs selected in Stage 1 for the final set of FBRs are shown.
The cost of a lowest-cost diet (GTQ/day) that includes the FBR or set of FBRs is shown for each target
group in Table 26 and Table 27. It is important to note that the calculated costs of putting the FBRs into
practice is inclusive of an existing “base diet”43 around which the FBRs would be implemented. In
Module 3, Optifood generates a “base diet” for the target group that is derived from the observed dietary
patterns to show the impact or nutritional value of putting the chosen FBR into place in the context of the
existing diet of the target group, showing this diet in either the worst-case (minimized) or best-case
(maximized) scenario. As such, the final cost of putting a complete set of FBRs into practice does not
equal the sum of putting each individual FBR into practice, but rather the sum of providing each
individual food in addition to necessary food required to maintain a very basic diet based on observed
intakes.
The full set of FBRs for children ranged from 2.0 GTQ/day to 5.2 GTQ/day and the full set of FBRs for
women ranged from 10.2 GTQ/day to 12.1 GTQ/day.
The four common messages across all target groups were to:
Consume Incaparina or fortified instant oats twice a day
Consume at least four different vegetables every day, including GLVs and chayote (Sechium edule)
Consume beans every day
Consume potatoes every day
Of these four messages, the message “to consume potatoes every day” was necessary only for children
6–8 months old and pregnant women (Table 28). This message could be changed to “consume potatoes at
least three times per week” for children 9–11 months old and non-breastfed children 12–23 months old.
This message was not required to ensure ≥ 70% of the micronutrient RDAs for breastfed children 12–23
months old and lactating women (Table 28). The sub-messages to include GLVs and chayote (Sechium
edule) were added to the vegetable FBR because they were important vegetable sources of micronutrients
in the best diets (Table 28).
43 Two diets (one minimized, one maximized) are constructed to compare the percent of the RNI for each individual nutrient in
Module 3 if FBRs were put into place in both the worst- (minimized) or best- (maximized) case scenarios in terms of the existing
diet. For each nutrient, Optifood calculates the percent RNI when it is minimized and maximized in diets that include the FBRs
and respect the set constraints (such as minimum breast milk consumption). For example, the percent RNI for calcium would be
shown in the context of a diet including FBRs where calcium content was minimized (base diet includes lowest amount of
calcium possible, given constraints) and maximized (base diet includes highest amount of calcium possible, respecting
constraints). As such, it is difficult to define just one base diet, but important to understand that the percent RNI covered by an FBR or set of FBRs shown for minimized diets is in the context of a very basic, existing base diet.
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Table 26. FBRs and the Cost (GTQ/day) of the Lowest-Cost Diet That Includes the FBR(s) for Children
FBR
Cost in GTQ/day for:
Breastfed Children 6–8 Months Old
Breastfed Children 9–11 Months Old
Breastfed Children 12–23 Months Old
Non-Breastfed Children 12–23 Months Old
Breastfeed your child on demand – – – –
Feed your child tortilla or tamalito at least three times per day
0.8 1.1 1.5 2.5
Feed your child Incaparina or fortified instant oats in porridge at least twice per day
0.9 1.2 1.7 2.7
Feed your child 4 servings of different vegetables every day, including GLVs and chayote (Sechium edule)
1.0 1.4a 1.9 2.8
Feed your child potatoes every day 0.9 1.2b 1.6c 2.6b
Feed your child black beans every day 0.8 1.1 1.5 2.9
Feed your child MPE every day 1.6 1.7 2.6 3.7
Full set of FBRs listed above 2.0 2.4 3.5 5.2 a The FBR for 4 servings of vegetables was not essential, but the message is then consistent with the younger children’s FBRs. An FBR for GLVs every day was sufficient. b The FBR to consume potatoes every day is consistent with the younger children’s FBRs. However, this FBR could be changed to “Feed your child potatoes at least three times per week.” c The FBR to consume potatoes every day is consistent with the younger children’s FBRs. However, this is not essential for breastfed children 12–23 months.
Table 27. FBRs and the Cost (GTQ/day) of the Lowest-Cost Diet That Includes the FBR(s) for Pregnant and Lactating Women
FBR
Cost in GTQ/day for:
Pregnant Women Lactating Women with Infants under 6 Months
Consume Incaparina or fortified instant oats at least twice per day 8.2 10.1
Eat at least four different vegetables every day, including GLVs and chayote (Sechium edule) 9.0 10.2
Eat potatoes every day 8.0 9.9a
Eat black beans every day 7.9 10.1
Eat liver at least once per week 7.9 10.0
Eat an orange at least three times per weekb 8.2 9.9c
Full set of FBRs listed above 10.2 12.1 a The FBR to consume potatoes every day is consistent with pregnant women’s FBRs. However, this is not essential for lactating women with infants under 6 months. b If oranges are only seasonally available, then a message to consume vitamin C-rich fruits and vegetables could replace the messages for oranges. c The FBR to consume oranges every day is consistent with lactating women’s FBRs. However, this is not essential for pregnant women.
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Table 28. Effect of Removing Individual Recommendations from the Set of FBRs for Each Target Groupa,b
Recommendation and the change made
Breastfed 6–8 months oldc
% RDA
Breastfed 9–11 months old
% RDA
Breastfed 12–23 months old
% RDA
Non-breastfed 12–23 months old
% RDA Pregnant Women
% RDA Lactating Women
% RDA
Incaparina or fortified instant oats 14 servings/week
None
7 servings/week
Ca 68%; B1 67%; B3 60%; Fe 29%; Zn 36% Fe 47%; Zn 48%
Fe 56%; Zn 43% Zn 57%
Ca 65%; B3 52%; Fe 35% Fe 54%
Ca 57%; B12 60%; Fe 45% Ca 65%; Fe 59%
Folate 56%; Fe 61%; Zn 55% Folate 63%; Zn 66%
Folate 58%; Zn 64% Folate 68%
Vegetables 4 servings/day
None
3 servings/day
Vitamin C 59%; Fe 61%; Zn 59% Vitamin C 65%; Fe 65%; Zn 59%
Vitamin C 59%; Zn 67% Zn 68%
Fe 64% Fe 67%
Ca 65%; Vitamin C 51%; Fe 69% Ca 67%
Folate 54% Folate 58%
Folate 67% Folate 69%
Black Beans 7 servings/week
None
3 servings/week
Fe 61%; Zn 59% Fe 63%; Zn 60%
Zn 68% Zn 69%
Fe 65% Fe 67%
Fe 68% OK
Folate 52% Folate 59%
Folate 55% Folate 61%
Potato 7 servings/week
None
3 servings/week
Vitamin C 64%; Fe 62%; Zn 58% Vitamin C 68%; Fe 64%; Zn 60%
Zn 69% OK
OK OK
Ca 69% OK
Folate 68% Folate 69%
OK
Staplesd 3 servings/day
2 servings/day
Fe 62%; Zn 58%
Zn 68%
Fe 67%
Ca 53%
Not applicable
Not applicable
MPE 7 servings/week
None
3 servings/week
Fe 61%; Zn 57% Fe 62%; Zn 58%
Zn 68% Zn 69%
Fe 67%; B12 54% Fe 68%
B12 34% B12 52%
Not applicable
Not applicable
Liver 1 serving/week
None
Not Applicable
Not Applicable
Not Applicable
Not Applicable
B12 16%; Folate 67%
B12 17%; Vitamin A 63%
Orange 7 servings/week
None
3 servings/week
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Folate 63% Folate 66%
Not Applicable Vitamin C 53%
a OK - All nutrients ≥ 70% RDA b Ca = calcium; Fe = iron; Zn = zinc c The FBR for children 6–8 months does not guarantee 70% iron and zinc; for iron = 67% and for zinc = 61%. d Staple foods for the target groups analyzed: tortillas and tamalitos made from white and yellow corn
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For all target groups, a combination of six or seven individual FBRs was required to ensure a nutritionally
optimal diet for most individuals in the target population. The most critical FBR for ensuring dietary
adequacy, for all target groups, was the FBR to consume 2 servings of either Incaparina or fortified
instant oats per day in porridge44 for children and in atoles or porridge for women (see rows 1 to 8 in
Appendices 22–27) (Table 29). However, this FBR did not ensure adequate iron and vitamin C for five
of the six groups; adequate calcium, folate, and vitamin B12 for four of the six groups; adequate zinc and
vitamin B6 for three of the six groups; and adequate vitamin A for two of the six groups. A combination
of additional FBRs was essential to improve levels of these nutrients in the selected worst-case scenario
diets (meaning that diets containing these foods would ensure nutrient adequacy for the majority of the
population).
In formulating sets of FBRs, efforts were made to create consistent messages across all target groups to
facilitate their promotion (Table 30 and Table 31). Encouraging similar improved dietary practices across
all target groups should help reinforce the messages and result in less disruption to family eating
practices. However, it also meant including an unnecessary FBR for some target groups, namely, to
consume potatoes daily.
44 The Spanish word for porridge is “papilla.”
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Table 29. Problem Nutrients in Modeled Optifood Diets That Came as Close as Possible to Meeting Nutrient Needs (from Module 3 results)
Breastfed Children 6–8 Months Old
Breastfed Children 9–11 Months Old
Breastfed Children 12–23 Months Old
Non-Breastfed Children
12–23 Months Old Pregnant Women
Lactating Women with Infants under
6 Months
Iron Not possible to meet requirement
Not possible to meet requirement without FBF
Not possible to meet requirement without FBF
Not possible to meet requirement without FBF
Not possible to meet requirement
Zinc Not possible to meet requirement
Not possible to meet requirement without FBF
Not possible to meet requirement without FBF
Not possible to meet requirement without FBF
Not possible to meet requirement without FBF
Vitamin B12 Not possible to meet requirement without FBF
Not possible to meet requirement without liver
Not possible to meet requirement without liver
Folate Not possible to meet requirement without FBF
Not possible to meet requirement without FBF
Vitamin C Not possible to meet requirement without oranges
Niacin Not possible to meet requirement without FBF
Not possible to meet requirement without FBF
Not possible to meet requirement without FBF
Not possible to meet requirement without FBF
FBF includes Incaparina or any other blended flour with the same micronutrient content as Incaparina.
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Table 30. FBRs without Including Micronutrient Supplementation for Children
In combination with other foods, breastfed children 6–8 months should consume at a minimum (Note: This diet does not meet iron and zinc requirements):
Food Frequency per
week Servings per day Estimated
serving size (g)a
Total quantity per day (g)
Tortilla or other maize products 7 3 20 60
Vegetables 7 4 20 80
Potatoes 7 1 55 55
Beans 7 1 25 25
FBF as porridgeb 7 2 10 20
MPE 7 1 20 20
In combination with other foods, breastfed children 9–11 months should consume at a minimum:
Food Frequency per
week Servings per day Estimated
serving size (g)a Total quantity
per day (g)
Tortilla or other maize products 7 3 25 75
Vegetables 7 4 25 100
Potatoes 7 1 60 60
Beans 7 1 25 25
FBF as porridgeb 7 2 10 20
MPE 7 1 30 30
In combination with other foods, breastfed children 12–23 months should consume at a minimum:
Food Frequency per
week Servings per day Estimated
serving size (g)a Total quantity
per day (g)
Tortilla or other maize products 7 3 25 75
Vegetables 7 4 35 140
Potatoes 7 1 60 60
Beans 7 1 30 30
FBF as porridgeb 7 2 15 30
MPE 7 1 35 35
In combination with other foods, non-breastfed children 12–23 months should consume at a minimum:
Food Frequency per
week Servings per day Estimated
serving size (g)a Total quantity
per day (g)
Tortilla or other maize products 7 3 50 150
Vegetables 7 4 40 160
Potatoes 7 1 75 75
Beans 7 1 60 60
FBF as porridgeb 7 2 15 30
MPE 7 1 40 40
a The estimated serving sizes are based on the dietary data collected in Huehuetenango and Quiché. b The FBF should have similar micronutrient content to Incaparina.
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Table 31. FBRs without Micronutrient Supplementation for Pregnant and Lactating Women
In combination with other foods (particularly tortillas and other maize products), pregnant women should consume at a minimum (Note: This diet does not meet iron requirements):
Food Frequency per
week Servings per day
Estimated serving size (g)a
Total quantity per day (g)
Vegetables 7 4 85 340
Potatoes 7 1 120 120
Beans 7 1 90 90
FBFb 7 2 25 50
Liverc 1 1 90 90
In combination with other foods, lactating women should consume at a minimum:
Food Frequency per
week Servings per day
Estimated serving size (g)a
Total quantity per day (g)
Vegetables 7 4 80 320
Potatoes 7 1 170 170
Beans 7 1 90 90
FBFb 7 2 30 60
Liverc 1 1 90 90
Orangesd 3 1 205 205
a The estimated serving sizes are based on the dietary data collected in Huehuetenango and Quiché.
b The FBF should have similar micronutrient content to Incaparina.
c Liver is included in the dietary recommendations so that pregnant and lactating women can meet vitamin B12 requirements. d If oranges are seasonally unavailable, then a message to consume the same quantity of other vitamin C-rich fruits and vegetables could replace the messages for oranges.
Messages differed slightly between children and women (Table 30 and Table 31). For children, a serving
of MPE every day and tortilla/tamalito three times per day were recommended, while the FBRs for
women included consuming liver once per week and oranges three times per week. Liver was not
modeled for children because it was not consumed by any child surveyed. Oranges were not required in
the modeled child diets to ensure nutrient adequacy. Messages to consume tortilla or tamalito were not
included in the FBRs for women because these foods were habitually consumed in amounts that would
help ensure dietary adequacy (i.e., minimum constraints on staples were 14 servings/week for pregnant
women and 20 servings/week for lactating women). For women, the feasibility of the recommendation to
consume oranges might depend on seasonal access. However, an FBR to consume any type of vitamin C-
rich fruits alone did not ensure dietary adequacy, which was likely due to the small serving size modeled
for lemons.
For all target groups, except children 6–8 months old and pregnant women, the selected set of FBRs, if
adopted, would ensure ≥ 70% for each of their nutrient RDAs was met. For children 6–8 months old,
≥ 70% of the iron and zinc RDAs were not achievable even with a realistic set of FBRs (Table 29). For
pregnant women, iron requirements are difficult to meet using food sources alone; ≥ 70% of the iron RDA
was not achievable even with a set of realistic FBRs. These results for pregnant women and children aged
6–8 months were not surprising because the optimized diets and best-case scenario diet,45 for zinc, were
below 70% of the zinc RDA. For iron, they remained below 100% of the RDA.
45 Diet modeled to provide the highest amount of zinc possible, based on local food and minimum and maximum constraints for
foods and food groups. An RDA of < 100% with the optimized diet shows that even with FBRs and a base diet providing the
greatest amount of zinc possible based on observed food patterns, it was not possible to achieve nutrient adequacy using local foods.
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In the worst-case scenario diets for all target groups, the number of nutrients remaining below 70% of
their RDAs decreased as the number of FBRs per set increased (Appendices 22–27). When only one
recommendation was tested, even for the best FBR evaluated, between five and seven nutrients did not
achieve 70% of the RDA, depending on the target group. This number decreased to between one to four
nutrients, when there were two FBRs per set; to between one and three nutrients when there were three
FBRs per set; to between one and two nutrients when there were four FBRs per set; and to between zero
and two nutrients when there were five FBRs per set, depending on the target group.
The most costly FBRs (analyzed using Module 4) were MPE, vegetables, and Incaparina and fortified
instant oats (Appendices 22–27). Of these, the FBR for MPE was the most expensive FBR for children,
ranging from an increase of between 48% and 100% of the cost of the lowest-cost diet available (a diet
that was modeled on meeting energy requirements and following existing dietary patterns only), without
following any dietary recommendations. For pregnant women, the FBR for vegetables was the most
expensive (an increase of 14% from the lowest-cost diet); for lactating women, it was the FBR for
Incaparina and fortified instant oats (an increase of 9%). For all target groups, the recommendation to
consume Incaparina or fortified instant oats twice per day increased the cost of the lowest-cost diets from
between 9% and 27% compared with the baseline of not adding any recommendation (i.e., following
observed dietary practices and meeting energy requirements) depending on the target group.
Children
The Module 2 best diet analyses showed that a diet based on current food patterns that would ensure
nutritional adequacy for all individuals in a target group was likely feasible only for non-breastfed
children 12–23 months old and only if Incaparina or fortified instant oats were consumed. For other child
target groups (breastfeeding children 6–8, 9–11, and 12–23 months old), iron, zinc, and/or calcium were
absolute problem nutrients, so 100% of their RDAs will be difficult to achieve using a behavior change
strategy based on current dietary patterns alone (Table 25). Nevertheless, the worst-case scenario
analyses, in Module 3, indicated that there was a set of FBRs that would ensure achievement of ≥ 70% of
the nutrient RDAs for all child target groups except children 6–8 months old. At these levels, the nutrient
needs of most children in each target group are likely to be met. For children 6–8 months old, alternative
strategies, such as micronutrient supplementation, would also be required to meet iron and zinc
requirements.
The most critical FBR for children was the FBR to consume 2 servings of either Incaparina or fortified
instant oats per day in porridge. It is very important to emphasize that children should not consume
Incaparina or fortified instant oats in an atole. The common preparation of atole is 4 tablespoons of
Incaparina or fortified instant oats (approximately 18.5 g/tbsp., giving a total of 74 g) per 1 L of water.
For a child 6–8 months old to consume the recommended total of 16 g/day of Incaparina or fortified
instant oats, he or she would need to consume 258 grams of atole, which is equivalent to about one full
meal given the estimated stomach capacity (237 grams) of a child 6–8 months old (Dewey and Brown
2003). Consuming this large quantity of atole could decrease the quantities of other foods also necessary
to meet nutrient requirements. In addition, it is likely that the atoles will be consumed in a bottle,
introducing hygiene problems. Therefore, the FBR is to consume Incaparina or fortified instant oats as
porridge.
Identical FBRs were formulated for all child target groups, because consistent messages will be
advantageous for FBR promotion. For this reason, the FBR to consume potatoes every day was included
in the set of FBRs for breastfed children 12–23 months old, even though it was not required to ensure
nutrient adequacy (Table 28 and Appendix 24).
An FBR for dairy products was not included in the final set of FBRs for children to avoid inadvertently
promoting the consumption of milk in place of breast milk. An FBR for fruit was not included in the final
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set of FBRs because it did not have a nutritional advantage over and above the other FBRs selected for
children (see Appendices 16–19). Further, fruits were generally not commonly consumed by these target
populations, so it might have been difficult to successfully promote them.
For children 6–8 and 9–11 months old, iron and zinc were the nutrients that were the most difficult to
achieve using locally available foods. For the children 6–8 months old, a set of FBRs that ensured ≥ 70%
of their iron and zinc RDAs was not achievable. For this target group, there were seven alternative sets of
FBRs that provided ≥ 70% of all nutrients except iron and zinc in the worst-case scenario diets. The
number of FBRs in these sets of FBRs ranged from four to the selected six messages (excluding the breast
milk message). The lowest costs of achieving these alternative sets of FBRs ranged from 1.1 to 2.0
GTQ/day compared to 2.0 GTQ/day for the selected set of FBRs for the children 6–8 months old.
However, in the cheaper sets of FBRs, the percentage of the RDAs achieved for iron and zinc were lower
than for the set of FBRs selected (57% vs. 67% and 55% vs. 61%, for iron and zinc, respectively; see
Appendix 22).
For children 9–11 months old, a recommendation to consume Incaparina or fortified instant oats in
porridge twice per day and vegetables four times per day ensured ≥ 70% RDAs of all nutrients except
zinc. Achievement of ≥ 70% RDA for zinc required the six FBRs selected. The difference in cost
comparing the two versus six message sets of FBRs was 0.7 GTQ/day (Appendix 23). For this age group,
14 alternative sets of FBRs achieved ≥ 70% RDAs of all nutrients except zinc.
For children 12–23 months old, calcium and iron were the most difficult RDAs to achieve, although
≥ 70% of all RDAs was achievable for three sets of FBRs (i.e., in two sets of FBRs for the breastfed and
in one set of FBRs for the non-breastfed children 12–23 months old) (Appendix 24 and Appendix 25).
For breastfed children, six alternative sets of FBRs achieved ≥ 70% of RDAs for all nutrients except iron.
Their numbers of messages (excluding the breast milk message) ranged from four to five. Their lowest-
cost diets ranged from 3.0 to 3.5 GTQ/day compared with 3.5 GTQ/day for the slightly superior (for iron)
set of FBRs selected. However, the percentage of the iron RDA achieved generally declined as the
lowest-cost diet’s price declined. For non-breastfed children 12–23 months old, achieving ≥ 70% the
calcium RDA was as challenging as achieving ≥ 70% of the iron RDA. One of the four-message sets of
FBRs and two of the five-message sets of FBRs achieved ≥ 70% of the iron RDA, but not the calcium
RDA. One five-message set of FBRs achieved ≥ 70% of the calcium RDA, but not the iron RDA. The
lowest-cost diet for these slightly inferior sets of FBRs ranged from 4.7 to 5.2 GTQ/day compared with
5.2 GTQ/day for the selected set of FBRs that achieved ≥ 70% of the RDAs for all nutrients.
Pregnant and Lactating Women
The Module 2 analyses showed that a nutritionally adequate diet was feasible for lactating women using
locally available foods, whereas iron, folate, and zinc were problem nutrients for pregnant women, so
achieving ≥ 70% of their RDAs using FBRs would be difficult. For lactating women, the message to
consume potatoes every day was not essential and could be omitted from the set of FBRs for this target
group. If oranges are available only seasonally, then a message to consume other vitamin C-rich fruits and
vegetables could replace the messages for oranges, although that might not guarantee that vitamin C
RDAs were met (Appendix 26 and Appendix 27).
For all women, the folate RDAs were the most difficult to achieve (without supplementation, which is
discussed below). Five sets of FBRs achieved ≥ 70% of RDAs for all nutrients except one (usually folate)
for both pregnant women and lactating women. The number of messages in these five sets of FBRs
ranged from four to five. Their lowest costs ranged from 9.9 GTQ/day to 10.2 GTQ/day compared with
10.2 GTQ/day for the FBRs that achieved ≥ 70% for all nutrients for pregnant women, and from 11.2
GTQ/day to 11.9 GTQ/day compared with 12.1 GTQ/day for lactating women. For lactating women, the
five-message set of FBRs that achieved ≥ 70% RDAs for all nutrients (potato message not included) was
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slightly cheaper than the six-message set of FBRs selected to test in community-based trials (i.e.,
11.8 GTQ/day vs. 12.1 GTQ/d). The FBR to consume liver once per week might be difficult to promote
because this food was rarely consumed. However, this FBR was critical for achieving the RDA for
vitamin B12.
3.4.5 FBRs without Micronutrient Supplementation:
As described above, for all target groups, a combination of four to seven individual FBRs was required to
meet or come as close as possible to meeting nutrient needs for individuals in all target groups. The final
set of FBRs developed for children (not taking into account micronutrient supplementation) is shown in
Table 30, and the FBRs without supplementation for women are shown in Table 31. If the FBRs were
adopted by the target groups as presented in Table 30 and Table 31, they would ensure a nutritionally
adequate diet for almost all target groups, except for children 6–8 months old and for pregnant women.
3.4.6 FBRs with Micronutrient Supplementation
The second set of analyses that were carried out with Optifood to develop FBRs allowed for the addition
of micronutrient supplements to the diet. This was included in recognition of the fact that the nutrient
needs of infants and young children are very high due to their rapid rate of growth and development
during their first 2 years and to test the effect of implementing FBRs in combination with the MSPAS-
recommended supplementation program. Breast milk can make a substantial contribution to the total
nutrient intake of children 6–23 months of age, particularly for protein and many of the vitamins, but
breast milk is relatively low in several minerals, such as iron and zinc, even after accounting for
bioavailability. Given that children 6–23 months of age consume relatively small amounts of
complementary foods, the nutrient density (amount of each nutrient per 100 kcal of food) of
complementary foods needs to be very high (PAHO 2003).
FBRs including supplementation for children. The diets of children surveyed did not include sufficient
animal-source foods and/or fortified complementary foods to meet their nutrient needs. In addition, local
fortified foods like Incaparina were consumed as a thin gruel (atole), which is low in nutrient density. The
inclusion of animal-source foods could increase the amount of iron and zinc in the diets of young
children. However, the cost of animal-source foods is relatively high and may not be affordable for
families in the Western Highlands. Furthermore, the amounts of animal-source foods that can feasibly be
consumed by infants under 12 months of age are generally insufficient to meet iron and zinc requirements
(PAHO 2003; WHO/UNICEF 1998). Therefore, it is necessary to promote more nutrient-dense
complementary foods, such as fortified complementary foods, prepared at the appropriate consistency,
and/or micronutrient supplements.
MSPAS supplementation protocols mandate that children 6–59 months of age should be given a multiple
MNP, but the composition that should be used is not specified in the norms (MSPAS 2004). At the time
of the survey, multiple MNP distribution was taking place in only a portion of the municipalities and
included several different multiple MNP formulations depending on the agency or donor. The Optifood
analysis included the WHO recommendation for multiple MNP composition of 12.5 mg of iron, 300 µg
of retinol, and 5 mg of zinc (WHO 2011). The WHO recommended duration and time interval for
supplementation with a multiple MNP is one sachet per day for a minimum period of 2 months, followed
by a period of 3–4 months off supplementation, so that use of the multiple MNP is started every
6 months.46
It is theoretically possible for all target groups to meet folate and vitamin C requirements from locally
available foods. However, the analysis using Optifood and the market prices survey suggests that it would
46 WHO. 2011. Guideline: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6–23 months of age. http://apps.who.int/iris/bitstream/10665/44651/1/9789241502047_eng.pdf.
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be complex (e.g., requiring the intake of at least four vegetable servings every day) and possibly too
costly for some families living in the Western Highlands (see cost results below). Therefore, a multiple
MNP that contains folic acid and vitamin C, in addition to iron, vitamin A, and zinc, could be beneficial
for the nutritional status of children 6–23 months. The composition of the Sprinkles include: 12.5 mg of
iron, 300 µg of retinol, 5 mg of zinc, 160 µg of folic acid, and 30 mg of vitamin C. The FBRs for children
6–23 months therefore include the Nutritional Anemia Formulation Sprinkle as summarized in Table 32.
Table 32. FBRs including Micronutrient Supplementation for Children
Supplementa Dosage
Multiple MNP 12.5 mg/day iron 300 µg/day retinol 5 mg/day zinc
160 µg/day folic acid 30 mg/day vitamin C
In combination with other foods, breastfed children 6–8 months should consume at a minimum:
Food Frequency per
week Servings per
day Estimated
serving size (g)b
Total quantity per day (g)
Tortilla or other maize products 7 2 20 40
Potatoes 3 1 55 55
Beans 3 1 25 25
Eggs 3 1 25 25
FBF as porridgec 3 1 20 20
Meat, poultry, or fishd 7 1 20 20
In combination with other foods, breastfed children 9–11 months should consume at a minimum:
Food Frequency per
week Servings per
day Estimated
serving size (g)b Total quantity
per day (g)
Tortilla or other maize products 7 2 25 50
Potatoes 3 1 60 60
Beans 3 1 25 25
Eggs 3 1 30 30
FBF as porridgec 3 1 20 20
Meat, poultry, or fishd 7 1 30 30
In combination with other foods, breastfed children 12–23 months should consume at a minimum:
Food Frequency per
week Servings per
day Estimated
serving size (g)b Total quantity
per day (g)
Tortilla or other maize products 7 4 25 100
Potatoes 4 1 60 60
Beans 4 1 30 30
Eggs 4 1 50 50
GLVs 4 1 30 30
FBF as porridgec 4 1 30 30
Meat, poultry, or fishd 7 1 35 35
In combination with other foods, non-breastfed children 12–23 months should consume at a minimum:
Food Frequency per
week Servings per
day Estimated
serving size (g)b Total quantity
per day (g)
Tortilla or other maize products 7 4 50 200
Potatoes 4 1 75 75
Beans 4 1 60 60
Eggs 5 1 50 50
GLVs 4 1 30 30
FBF as porridgec 5 1 30 30
Meat, poultry, or fishd 7 1 40 40 b The estimated serving sizes are based on the dietary data collected in Huehuetenango and Quiché.
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c The FBF should have similar micronutrient content to Incaparina. d This recommendation is not necessary to meet micronutrient requirements if a multiple MNP is consumed. However, the
recommendation is included because WHO recommends that children 6–23 months of age consume meat, poultry, fish, or eggs daily,
or if daily consumption is not possible, as frequently as possible.
FBRs for pregnant women. The consumption of locally available foods generally cannot meet the
nutrient requirements of pregnant women for iron and folate given their high requirements for those
micronutrients. Therefore, WHO recommends that pregnant women consume iron and folic acid
supplements during pregnancy (WHO 2012a). In alignment with WHO recommendations, the MSPAS
protocol is for pregnant and lactating women to consume 600 mg of ferrous sulfate and 5 mg of folic acid
once per week (MSPAS 2004). The FBRs summarized in Table 33 include the iron and folic acid
supplementation as recommended by MSPAS.
Table 33. FBRs with Micronutrient Supplementation for Pregnant and Lactating Women
Supplementa Dosage
Iron and folic acid supplementation
600 mg/week ferrous sulfate 5 mg/week folic acid
In combination with other foods, pregnant women should consume at a minimum:
Food Frequency per
week Servings per day Estimated
serving size (g)b
Total quantity per day (g)
Fortified cerealc 7 1 25 25
Vegetables 7 4 85 340
Potatoes 7 1 120 120
Liverd 1 1 90 90
In combination with other foods, lactating women should consume at a minimum:
Food Frequency per
week Servings per day Estimated
serving size (g)b
Total quantity per day (g)
Fortified cerealc 7 1 30 30
Vegetables 7 4 80 320
Potatoes 7 1 170 170
Liverd 1 1 90 90
Orangese 3 1 205 205 a Supplement content and dosage is based on MSPAS 2004. b The estimated serving sizes are based on the dietary data collected in Huehuetenango and Quiché. c The fortified cereal should have similar micronutrient content to Incaparina. d Liver is included in the dietary recommendations so that pregnant and lactating women can meet vitamin B12 requirements.
e Oranges could be replaced with another fruit or vegetable with high vitamin C content.
3.4.7 Alternative Best Sets of FBRs
A final analysis was done to identify the best set of FBRs for each target group given the desired number
of individual FBRs to promote (Appendices 22–27). This information can be used to select alternative
sets of FBRs for different target groups when fewer than six messages are desired or if one or more of the
FBRs is determined to be infeasible/unacceptable for the target population/context. These sets of FBRs
were selected on the basis of the number of nutrients at < 70% of their RDA in the worst-case scenario
diets and their lowest cost when compared to other FBRs in their message number category. A message to
consume Incaparina or fortified instant oats twice a day was the only consistent message in all best
alternative sets of FBRs selected for all target groups. A message to consume liver once per week was in
all best alternative sets of FBRs selected for pregnant and lactating women.
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3.4.8 Analysis of Four Fortified Cereal Blends: Incaparina, Incaparina-Crecimax,
Vitacereal, and Corn-Soy Blend
Programs aiming to reduce chronic malnutrition in Guatemala often include distribution of an FBF. For
example, the World Food Programme (WFP) has supported the distribution of Vitacereal47 and the
USAID-funded Title II Development Food Assistance Program distributes a corn-soy blend (CSB).48
However, global evidence suggests that FBFs are not appropriate to meet the nutritional needs of young
children, for several reasons (De Pee and Bloem 2009).
They do not contain all the required nutrients in adequate amounts.
They contain a relatively large amount of antinutrients and fibers, especially when prepared from
non-dehulled soybeans and non-degermed, non-dehulled maize or wheat.
They do not provide enough energy per serving and are bulky.
The overall fat content and essential fatty acid levels are low.
They contain no milk powder, which increasingly appears to be important for linear growth of
young children.
Despite the known limitations of FBFs, additional analysis was undertaken using Optifood to assess
whether Incaparina, Incaparina-Crecimax, Vitacereal, or CSB could contribute to the micronutrient
content of the diet of the target groups with the highest nutrient requirements and the most limited gastric
capacity, namely, breastfed children 6–8 months old and breastfed children 9–11 months old
(Appendix 28).
Each of the four FBFs was tested separately in combination with the final set of FBRs developed for
children (without micronutrient supplementation), including the maximum number of FBRs allowable
given energy constraints on the diet (2 servings per day of staples, 4 servings per day of vegetables, 1
serving per day of MPE, and 1 serving per day of beans). The quantities of FBFs tested were based on the
serving size of Incaparina based on the cross-sectional survey and increased to reflect a thicker
preparation of the cereal in porridge (a 50% greater serving size). For children 6–8 months old, the
estimated serving per day was 27 grams of fortified cereal blend. For children 9–11 months old, the
estimated serving per day was 30 grams. The results of the analysis are shown in Appendix 29 and
Appendix 30.
Incaparina
Incaparina alone does not provide sufficient quantities of calcium, vitamin C, vitamin B6, and iron for
breastfed children 6–8 months old or breastfed children 9–11 months old. However, Incaparina has a high
zinc content compared to the other fortified cereal blends and ≥ 70% of the RDA for zinc was met even
when Incaparina was tested without additional FBRs for both target groups.
For children 6–8 months old, it was not possible to achieve ≥ 70% of the RDA for vitamin C and iron,
even when Incaparina was consumed in combination with the maximum number of FBRs allowable given
47 Vitacereal is a fortified, maize-soy meal produced in Guatemala and distributed by the GOG as part of its social programs. This
complementary food is fortified with iron, zinc, calcium, thiamine, riboflavin, vitamin B6, vitamin A, vitamin D, vitamin E,
vitamin C, niacin, folic acid, vitamin B12, and iodine. Vitacereal is specifically marketed as a complementary food for children 6–23 months of age and also for pregnant and lactating women. 48 CSB is a fortified corn-soy flour that is provided in USAID Food for Peace Title II food assistance programs in Guatemala.
CSB is fortified with vitamin A, vitamin D, vitamin E, vitamin K, thiamine, riboflavin, niacin, vitamin B6, folate, vitamin B12,
vitamin C, biotin, iodine, iron, zinc, potassium, calcium, and phosphorus. Please note the CSB currently provided in Guatemala is not CSB+, which is a CSB product with improved amounts and forms of vitamins and minerals in the vitamin/mineral premix.
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energy constraints on the diet. For children 9–11 months old, all nutrient requirements were achievable
when Incaparina was recommended in combination with at least 2 servings per day of staples and
4 servings per day of vegetables.
Incaparina-Crecimax
Incaparina-Crecimax is marketed as a fortified food product formulated to promote growth among
children starting at 9 months of age. It contains a higher level of micronutrients than the traditional
formulation of Incaparina, with the exception of zinc (Incaparina-Crecimax contains 10.7 mg/day of zinc
and Incaparina contains 16.0 mg/day). For breastfed children 6–8 months old, the sole recommendation of
consuming Incaparina-Crecimax twice per day met ≥ 70% of the all the RDAs except for zinc;
Incaparina-Crecimax in combination with 2 servings per day of staples and 4 servings per day of
vegetables met ≥ 70% of the RDA for zinc. For breastfed children 9–11 months old, the sole
recommendation of Incaparina-Crecimax met ≥ 70% of the all the RDAs.
Vitacereal
For breastfed children 6–8 months old, it was not possible to achieve ≥ 70% of the RDAs for calcium,
iron, and zinc when Vitacereal was tested, even in combination with 2 servings per day of staples and
4 servings per day of vegetables. When tested with the maximum number of FBRs allowable given
energy constraints on the diet, Vitacereal still could not meet iron and zinc requirements for children 6–8
months old. For breastfed children 9–11 months old, Vitacereal could not achieve ≥ 70% of the RDA for
zinc when tested in combination with 2 servings per day of staples and 4 servings per day of vegetables.
However, Vitacereal could achieve ≥ 70% of the RDA in combination with the maximum number of
FBRs allowable given energy constraints on the diet.
CSB
CSB alone does not provide sufficient quantities of niacin, iron, and zinc for children 6–8 months old or
iron and zinc for children 9–11 months old. When combined with the maximum number of FBRs
allowable given energy constraints on the diet, a diet including 2 servings of CSB per day was able to
meet all nutrient requirements except for zinc for children 6–8 months old and children 9–11 months old.
3.4.9 Cost Analysis
Module 4 was used to carry out an analysis separate from that used to develop and test FBRs in order to
identify the lowest-cost nutritionally best diet possible, given local foods and local dietary patterns, and to
provide information on the nutritional content of this diet and how much it would cost to provide nutrient
adequacy. Table 34 shows the total cost of the lowest-cost nutritionally best diet, the foods that contribute
≥ 10% of cost, and the highest percentage of the RDA achievable in the diet. This table shows how much
it would cost to provide nutritionally adequate diets (or “best-case scenario” diets) for individuals in the
target groups. The cost of the lowest-cost nutritionally best diets selected in Module 4 ranged from 1.8
GTQ/day for children 6–8 months old to 19.1 GTQ/day for lactating women. Except for fat, these diets
achieved 100% of the RDAs for all nutrients for lactating women and non-breastfed children. For other
target groups, these lowest-cost nutritionally best diets met or exceeded the RDAs for all nutrients, except
the problem nutrients (iron and zinc for children 6–8 months old and iron for pregnant women). The
most-expensive foods in these lowest-cost nutritionally best diets were eggs, chicken, Incaparina,
tamalito, and tortilla. The high cost of the last two reflects the large quantity required to meet RDAs.
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Table 34. Lowest-Cost Nutritionally Best Dieta for Each Target Group
Target group Cost
(GTQ/day) Cost
(US$/day) Foods ≥ 10% of costb Nutrients < RDAsc
Breastfed 6–8 months old
1.8 0.22 Tortilla, or other maize product (24%)
Egg (11%) Incaparina (10%)
Calcium (97% RDA)
Iron (94% RDA) Zinc (64% RDA)
Breastfed 9–11 months old
2.6 0.33 Egg (21%) Tortilla, or other maize product (10%)
Zinc (77% RDA)
Breastfed 12–23 months old
4.3 0.54 Egg (35%) Iron (91% RDA)
Non-breastfed 12–23 months old
5.7 0.72 Eggs (17%) Tortilla, or other maize product (16%)
Bread (13%)
Fat (60% of recommended)
Pregnant women
15.6 1.99 Tortilla, or other maize product (28%)
Chicken (12%)
Folate (96% RDA) Zinc (90% RDA) Fat (56% of recommended)
Lactating women
19.1 2.43 Tortilla, or other maize product (39%) Fat (46% of recommended)
a Not including micronutrient supplementation b Value in parentheses is the percentage of the total cost for that food. c Value in parentheses is the highest percentage of the RDA achievable and the value achieved in the lowest-cost nutritionally best diet.
The foods selected in the lowest-cost nutritionally best diets for each target group are presented in
Table 35. The blank spaces in this table show foods that were not included in the food list for a target
population. The zeroes indicate foods that were not selected in the lowest-cost nutritionally best diet for
that target group even though they were in the food list. Foods that were not selected in the lowest-cost
nutritionally best diet for any target group are not presented in this table.
Tortilla (yellow corn), Incaparina, milk, eggs, and fortified sugar were selected in the lowest-cost
nutritionally best diets for all target groups. Of these foods, fortified sugar was forced into all modeled
diets by the model constraints because it was consumed by the surveyed population. Tamalito
(yellow/white corn), fortified instant oats, chayote (Sechium edule), cheese, tomato, and amaranth leaves
were selected in the diets of five of the six target groups. Nightshade leaves (hierba mora [Solanum
tuberosum]) were selected in all the lowest-cost nutritionally best diets for children. Chicken, chicken
broth, bread, and oil were selected in all the lowest-cost nutritionally best diets of target groups that were
not consuming breast milk, presumably to increase diet fat content.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Table 35. Food Selected for Lowest-Cost Nutritionally Best Diets for Each Target Group*
Foods
Breastfed 6–8 months
servings/week
Breastfed 9–11 months
servings/week
Breastfed 12–23 months servings/week
Non-breastfed 12–23 months servings/week
Pregnant servings/
week
Lactating servings/
week
Tortilla, yellow corn 14 14 14 12 11 14 Tortilla, white corn Tamalito, y/w Incaparina Fortified instant oats Non-fortified instant
oats Pasta, enriched Bread, sweet Milk Cheese Potatoes Tomatoes Tree tomato Husk tomato Carrots Chayotea Nightshade leafb Amaranth leaf Crotalaria leaf Turnip greens Cabbage Pumpkin Peas, green Beans, snap, green Spring onion Onion Lemons Orange Banana Egg Chicken Frankfurter Lamb Liver Black bean, cooked Black beans, dry Protemas, soy Broth, beans Broth, chicken Broth, beef Soup, dehydrated,
chicken noodle Soup, dehydrated,
ramen noodle Sugar, fortified Coffee Oil
0 7 7 7 0 0 0 6 1 6 7 – – 5 4 4 3 0 0 – – – – 3 2 1 0 0
1.5 0 – – – 5 1 1 0 0 – 0 – – – 3 0 0 –
7 0 7 3 4 0 0 6 1 4 7 4 – 0 4 4 3 – – – 1
0.2 – – 0 0 0 0 5 0 0 – – 4 3 – 4 0 – 0 – – – 5 0 0 –
0 7 7 7 0 0 0 1 1 1 7 – – 1 5 4 1 2 – – 2 1 – 3 2 7 0 0 7 – 0 – – 0 7 – 0 0 – 0 – – – 5 7 0 –
0 14 7 7 0 0 7 7 0 0
0.1 2 0 0 0 7 0 – 0 3 0 – 3 3 0 7 0 0 5 1 – 1 – 0 – – 0 4 3 0 – 2 – 5 7 3 –
0 10 7 7 0 5 7 6 1 7 7 – – 2 3 0 5 0 2 – 1 – – 4 3 0 7 1 4 2 1 1 1 3 5 – – 5 – 7 – 2 – 5 7 4 –
1 10 7 0 7 0 7 6 1 0 0 4 – 0 4 0 7 0 0 2 4 – – 7 0 0 0 0 4 2 1 – 1 7 0 – – 7 – 7 – – – 5 7 5 –
* The blank spaces in this table show foods that were not included in the food list for a target population. The zeroes indicate foods that were
not selected in the lowest-cost nutritionally best diet for that target group even though they were in the food list. Foods that were not selected
in the lowest-cost nutritionally best diet for any target group are not presented in this table. a Sechium edule b Hierba mora (Solanum tuberosum)
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4. Discussion
The results of the cross-sectional survey undertaken as part of this study are consistent with previous
studies in the Western Highlands that have shown high levels of chronic malnutrition, poor
complementary feeding practices, and low dietary diversity (MSPAS 2010; Vossenaar et al. 2013). The
study participants came from predominantly rural, indigenous households characterized by a high
prevalence of stunting and anemia. By the end of the first year of life, already almost half of children in
the study population (47.3%) were stunted.49 In the second year of life, the prevalence of stunting
increased to 70.5% of children. The overall prevalence of wasting among children 6–23 months was very
low at 1.3%.50
Roughly half of the households surveyed experienced anxiety or concern regarding food security in the
30 days preceding the survey, although few households reported experiencing hunger according to the
subset of questions focused on lack of food. Moreover, results from the Optifood analysis confirmed that
the largest problem in the diets of the women and children surveyed was related to diet quality, not to the
amount of food consumed in terms of energy and calories.
The diets of participating women and children were largely plant based, with few animal-source foods or
fortified foods. Maize products (e.g., tortillas, atole made of corn dough) and sugar constituted half of the
energy in the diets of children and two-thirds the energy of women. A largely plant-based diet with few
animal-source or fortified foods is disadvantageous, because of the relatively high content of
antinutrients, the lower bioavailability of certain micronutrients, and the lack of specific nutrients and
active compounds contained in animal-source food (De Pee and Bloem 2009). Accordingly, the iron and
zinc densities of complementary foods consumed by children 6–11 months old in this population were
inadequate.
The amount of energy consumed by all child target groups in both departments was considered adequate.
The mean estimated energy and protein intake for pregnant and lactating women in both departments was
low compared to their estimated requirements. However, given the variability in the amounts consumed,
looking at average consumption makes it difficult to assess if actual intakes were low.
Although protein intake from complementary foods for all child target groups in both departments was in
the “adequate” range, the quality of protein may be inadequate considering that the majority of the protein
in the diet was from maize and that very few animal-source foods were consumed. The 24-hour recall
data showed that grains and legumes were not often consumed together, resulting in inadequate essential
amino acids for a complete protein.
The dietary analysis conducted using Optifood as part of this study found similar results to previous
studies in Guatemala with regard to problem nutrients (i.e., calcium, iron, zinc, folate, and vitamin B12)
(Vossenaar and Solomons 2012; Dewey and Brown 2003). The problem nutrients identified by Optifood
also coincide with deficiencies in iron, zinc, and vitamin B12 among children and women identified in the
2009–2010 Encuesta Nacional de Micronutrientes (ENMICRON) (National Survey of Micronutrients)
(Table 36) (MSPAS 2011).
49 http://www.who.int/childgrowth/en/. 50 http://www.who.int/childgrowth/en/.
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Table 36. Prevalence of Micronutrient Deficiencies among Children 6–59 Months Old and Women 15–49 Years Old, ENMICRON, 2009–2010
Characteristic
Prevalence of micronutrient deficiency (%)
Iron Zinc Vitamin B12
Children Women Children Children Women
Urban 29.7 16.4 24.8 10.1 16.4
Rural 24.0 20.1 41.8 14.7 21.1
Non-indigenous 26.1 18.1 29.8 9.6 17.7
Indigenous 26.7 17.3 41.2 16.9 20.8
For all target groups, a combination of six or seven individual FBRs was required to ensure that the diet
provided ≥ 70% of all micronutrient RDAs (apart from iron and zinc for children 6–8 months old and iron
for pregnant women). In addition, most individual FBRs in the final set of FBRs were already at their
highest food group constraint levels (i.e., at their maximum number of servings per week from a food
group according to the target groups’ dietary patterns). Adoption of the final set of FBRs will therefore
require a shift away from the target groups’ usual food consumption patterns. Nevertheless, all FBRs fell
within the observed range of dietary practices of the target groups, suggesting that they can be
successfully promoted. Still, it will require a well-designed behavior change intervention to successfully
promote them.
Maize, GLVs, black beans, Incaparina, and fortified instant oats were important sources of problem
nutrients. Thus, the FBRs rely predominantly on these foods to meet nutrient requirements. However,
questions can be raised about the high content of antinutrients and low bioavailability of iron, zinc, and
calcium from these plant-based food sources. Low bioavailability was taken into account via the RDAs
used in the analyses. These conservative RDAs might have overestimated the extent of the problem for
young children, except that the FBR to consume MPE every day might not improve iron and zinc
bioavailability, if eggs instead of flesh foods are consumed. Eggs were the most common foods consumed
from the MPE food group.
For children 6–8 months old, the high densities of iron and zinc recommended in complementary foods
could not be achieved, even when locally available fortified foods (Incaparina and fortified instant oats)
were included in the FBRs. For this target group, alternative strategies are required for iron and zinc
requirements to be met. Similarly, a diet based on locally available foods cannot meet the requirement for
iron for pregnant women.
Additional analysis was undertaken to assess the extent to which Incaparina, Incaparina-Crecimax,
Vitacereal, or CSB could contribute significantly to improving the quality of the diet of the target groups
with the highest nutrient requirements and the most limited gastric capacity, namely, breastfed children
6–8 months old and breastfed children 9–11 months old. Incaparina-Crecimax, without any additional
FBRs, met ≥ 70% of the all the RDAs for breastfed children 9–11 months old and all the RDAs, except
for zinc, for breastfed children 6–8 months old. For breastfed children 6–8 months old, it was not possible
to achieve ≥ 70% of all the RDAs with Incaparina, Vitacereal, or CSB, even when the fortified cereal
blends were tested in combination with other FBRs. For breastfed children 9–11 months old, it was not
possible to achieve ≥ 70% of all the RDAs with CSB, even when the fortified cereal blends were tested in
combination with other FBRs.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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These results indicate that interventions using fortified cereal blends tested in this analysis are not
sufficient to address problem nutrients, especially iron and zinc, among breastfed children 6–11 months
old. The findings are consistent with previous research in Haiti that assessed whether adding CSB to diets
of children 6–23 months old would ensure nutrient adequacy (Ruel et al. 2004). Furthermore, these
fortified cereal blends are not suitable as a food supplement for young children for additional reasons,
including their relatively large content of antinutrients and fibers; overall low fat content; low level of
essential fatty acids; and lack of milk powder, which may have important effects on children’s linear
growth.
Other disadvantages of fortified cereal blends available in Guatemala include the tendency to prepare
them as atoles (e.g., 75 g of Incaparina in 1,000 mL of water). Although INCAP has developed and
promoted recipes for preparing Incaparina in porridge form, the practice of preparing porridges from
Incaparina is very limited (e.g., none of the respondents in the cross-sectional survey report consuming
Incaparina in porridge). In addition, it is common practice to prepare atole once per day for the entire
family and not to prepare special foods for young children. Therefore, although the FBRs include
preparing Incaparina as porridge, the feasibility and acceptability of this recommendation needs to be
field tested.
It was necessary to combine FBRs with micronutrient supplements to meet the nutrient requirements for
zinc and iron for children 6–8 months old and the requirement for iron for pregnant women. In addition to
micronutrient supplements, for all target groups, a combination of four to seven individual FBRs was
required to ensure that dietary adequacy of all nutrients was met. To maintain consistency of
recommendations across target groups, the FBRs for children and pregnant and lactating women should
be promoted in conjunction with micronutrient supplementation.51 While Optifood analyses that included
appropriate micronutrient supplements for both children and women were carried out, the analyses did not
specifically consider the full range of MSPAS supplementation policies. As a part of next steps discussed
below, there is a need to assess and review MSPAS supplementation policies with the information gained
in this analysis, using the Optifood tool.
The lowest-cost nutritionally best diets ranged from 1.8 GTQ (US$0.22)/day for children 6–8 months old
to 19.1 GTQ (US$2.43)/day for lactating women. Half of the population living in the five departments of
the Western Highlands earns less than 25 GTQ/day (US$3.13/day), and 15% of the population earns less
than 12 GTQ/day (US$ 1.50/day) (INE 2011). The average household size among the study population is
seven people. Therefore, putting a nutritionally adequate diet in place for young children and pregnant
and lactating women, in addition to other family members is probably not affordable for the majority of
households in the Western Highlands.
Multiple constraints may prevent families from implementing the FBRs. Programs that provide
micronutrient supplementation—using either FBFs or a multiple MNP—and that are contemplated by the
GOG could also help in this regard. Other constraints, such as time required to prepare food and fuel
needed, should be further explored to develop effective strategies for supporting a nutritionally adequate
diet for the most vulnerable groups
51 Recommended supplementation for children 6–23 months old include 12.5 mg/day of iron, 300 µg/day of retinol, 5 mg/day of
zinc, 160 µg/day of folic acid, and 30 mg/day of vitamin C, and for pregnant and lactating women include 600 mg/week of ferrous sulfate and 5 mg/week of folic acid.
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5. Challenges in Using Optifood to Develop FBRs
It is important to note a number of challenges regarding the implementation of a comprehensive dietary
analysis as was done with Optifood.
This study required the collection of high-quality dietary data from a randomized sample of multiple
target groups so that the target population’s actual food consumption practices would be accurately
captured. Daelmans et al. (2013) recommend 24-hour dietary recalls, based on the ProPan methodology,
for use in collecting input data for Optifood analysis. This data collection process is lengthy and detailed,
requiring well-trained staff for fieldwork and data entry. Working with an experienced local partner with
a strong research capacity was found to be extremely helpful. Using staff who were well trained in the use
of dietary assessments and adapting previously validated instruments significantly reduced the amount of
time required for dietary data collection.
Another important challenge is finding staff with the skills required to prepare the dietary and FCT data
for Optifood analysis. This analysis requires considerable attention to accurately examine the quality of
the FCT values, impute missing values, and prepare all dietary data. It would be useful to develop
computer software to simplify this process. Until then, the effort and skills required for data preparation
will remain a hurdle to using Optifood. In addition, the time required to fully analyze each target group
should not be underestimated, as at least 1 day per target group is required, even by operators who are
well trained in the use of the program. And, since some FBRs can be strategically proposed across various
target groups, sufficient time is needed to ensure that recommendations are, to the extent feasible,
consistent across target groups.
A further challenge is managing the effect of seasonality on food availability, production cycles, and
consumption. The application of Optifood for this analysis did not take seasonality into account; thus, the
recommendations identified refer essentially to the season during which data were collected. Further field
testing (such as through the use of household trials) will be needed to verify whether the FBRs would be
appropriate during other times of year or whether alternative recommendations are needed.
It is important to acknowledge the geographic limitations posed by a cross-sectional survey that captures
a snapshot of dietary patterns and food cost/availability in a restricted area, as was done here in the two
surveyed departments. Further testing of the FBRs in other departments and geographic areas would also
allow for greater consideration of whether the recommendations would be appropriate for use outside of
Huehuetenango and Quiché.
Given the scope of this project, another limitation was the small sample size for individual target groups,
which meant that model parameters for FBRs were defined from a limited number of data points. Special
effort was needed to carefully scrutinize the consistency of model parameters both within and across
target groups and regions. Although a larger sample size is not likely to have changed the foods selected
for the final FBRs, it might have increased the accuracy of the estimated serving sizes of nutrient-dense
foods. Despite this limitation, the high-quality data entered into Optifood during the Guatemala work
resulted in a quality analysis that provides valuable insight into recommended approaches to improve
nutrient intake.
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6. Next Steps
The analysis provided technical information regarding problem nutrients, best food sources for nutrients,
FBRs that could meet or come as close as possible to meeting the nutrient needs for individuals in the
target groups, and the cost of consuming a diet that meets or comes as close as possible to meeting
nutrient needs. However, questions remain regarding food availability and the feasibility, and
affordability of implementing the FBRs and strategies needed to bridge nutrient gaps in the local food
supply. Therefore, an immediate next step for USAID/Guatemala, the GOG, and partners is to review the
results of the analysis, in the context of their experience and current programs, and to select the most
promising programmatic options to improve the nutrient intake of women and children, which may
include promotion of FBRs through behavior change, promotion of agriculture or animal husbandry, food
fortification, supplementation with micronutrients, or other approaches. The following issues should be
considered.
1. Role of agricultural interventions. The analysis identified several important food sources for
problem nutrients that could be promoted through agricultural interventions, including increasing
production and availability and access of low-cost GLVs, black beans, and animal-source foods.
More information is needed regarding the feasibility of home production of these foods, including
the quantities of foods that need to be produced, the time burden or opportunity cost required to
produce or cook foods, current levels of production, seasonality, and requirements for production
(e.g., seeds, inputs, water, etc.).
2. Existing food fortification and micronutrient supplementation policies. The GOG already has
in place several fortification and supplementation laws.52 For example, MSPAS norms include
commercial fortification of sugar with vitamin A; salt with iodine and fluoride; and wheat flour
(WHO 2012b) with iron, thiamine, riboflavin, niacin, and folate acid. Policies on supplementation
include routine MSPAS provision of vitamin A every 6 months to children 6–59 months of age,
iron and folic acid supplementation for pregnant and lactating women, and multiple MNP for
children 6–59 months of age (in place of iron and folic acid) (MSPAS 2000; MSPAS 2004).
MSPAS also provides zinc as a therapeutic treatment for children with diarrhea. These policies
need to be analyzed for their complementarity (or redundancy) of micronutrient approaches, their
effectiveness to meet desired objectives (e.g., prevent anemia, promote linear growth), and their
relationship to the findings presented in this report.
3. Complementary food supplements.53 This analysis indicates that the iron and zinc densities of
complementary foods consumed by young children surveyed are inadequate. In addition, it seems
that locally available FBFs do not meet the nutrient requirements of children 6–11 months old.
Some households may not be able to consistently afford animal-source foods. Complementary
food supplements, depending on the type (e.g., multiple MNP, lipid-based nutrient supplements),
provide essential micronutrients, amino acids, fatty acids, and/or active compounds (enzymes).
More analysis is required to evaluate the need for and the effectiveness and feasibility of
complementary food supplements.
4. Feasibility and affordability of FBRs. More work is needed to ensure that the FBRs are realistic
and practical. After consultation with USAID/Guatemala, the GOG, and partners to reach general
consensus around the FBRs, the feasibility of successfully promoting these specific FBRs should
be evaluated via household trials in the Western Highlands (Dicken and Griffiths 1997). Some
52 CONAFOR. 2010. “Consolidado de Legislación para Fortificación de Alimentos.” http://www.conafor.org/pp/bancofotos/326-6131.pdf. 53 Complementary food supplements are defined as food-based supplements that can be mixed with or consumed in addition to the diet to add nutritional value (adapted from De Pee and Bloem 2009).
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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testing of the FBRs has already been initiated; from June to August 2013, Nutri-Salud, INCAP,
and LSHTM, with technical input from FANTA, tested the feasibility of FBRs for children 6–11
months in Chiantla, one of the prioritized municipalities of Huehuetenango (Knight 2013). These
activities used a combination of methods from the ProPAN and Designing by Dialogue resources
for running Trials of Improved Practices (TIPs) (Dicken and Griffiths 1997; PAHO 2013). The
results of the TIPs found that mothers of children 6–11 months were willing to try several of the
FBRs for this age group, particularly preparation of thick porridges and use of potatoes in
children’s food. Other FBRs were more challenging to implement, such as recommended daily
consumption of beans and animal-source foods.
Building on these results, during 2014, FANTA, INCAP, and Nutri-Salud will further develop the
findings from the Optifood analysis, support additional household trials of FBRs, and provide
technical assistance to partners to address nutrient gaps through policy and programming
strategies. Further exploration is needed on FBRs for children 6–11 months, along with FBR
trials for children 12–23 months. For example, in Quiché, alternatives to the recommendation for
daily potato consumption should be explored given stakeholders’ comments that potatoes are
rarely produced at the household level in Quiché and are not readily available. Additional FBR
trials are also required because of the different prevalent socio-ethnographic groups in Quiché
(Ixil and Quiché) versus Huehuetenango (Mam). Trials of FBRs for women should address the
feasibility of pregnant women consuming liver once a week and oranges daily, as per current
FBRs. Furthermore, FBR trials for women are needed to assess their feasibility given women’s
other time commitments for child care and food production and the fuel requirements, among
other considerations. Planned trials during 2014 will identify individual FBRs that are feasible for
families to implement, as well as barriers and potential motivating factors to help encourage their
adoption. The final outcomes from such trials will be a realistic set of evidence-based,
population-specific FBRs, and the content for messages to promote them in the Western
Highlands.
5. Strengthening agricultural/nutrition linkages. The results provided here can inform
government strategies in promoting the production and consumption of foods identified in the
FBRs. Collaboration with the Ministry of Agriculture and Livestock in developing extension
programs that support the production of nutrient-dense foods and with MSPAS in developing
SBCC messages that help consumers optimally integrate those foods in their diets are promising
areas of investment.
6. Use of findings to develop messages for a social and behavior change strategy and program
activities. Based on the household trials and the resulting key messages, it is recommended that
the GOG and other cooperating agencies (including Nutri-Salud) consider using the results of this
project for the design of SBCC strategies that include activities aimed at promoting the FBRs
among target groups
7. Applicability of the FBRs to other areas of the Western Highlands. Studies are needed to
determine if the FBRs may be applicable to other areas within the Western Highlands. The data
used to set the model parameters in Optifood through the cross-sectional survey came from a
limited area of the Western Highlands. Despite the variation in ecological zones and
ethnolinguistic groups between the two departments, the results of the cross-sectional survey
show that the dietary patterns and locally available foods of the two study areas were similar. As
a result, common dietary recommendations were developed for both study areas. However, the
extent to which the dietary recommendations could be applied to other areas of the Western
Highlands still needs to be assessed.
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8. Involving the private sector. The Optifood results were shared with private sector companies in
Guatemala that are involved in manufacturing complementary foods. The Optifood results
generated their interest in tailoring some of their products using the micronutrient formulation
suggested by Optifood. Further work is under way to extend this into collaboration to field test
complementary food products currently under development. There is excellent potential for such
collaboration, in terms of increasing access to optimal products at scale.
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Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc.
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Otten, Jennifer J.; Pitzi Hellwig, Jennifer; and Meyers, Linda D. (eds.). 2006. “Dietary Reference Intakes:
The Essential Guide to Nutrient Requirements.” http://www.nap.edu/catalog/11537.html.
PAHO. 2003. Guiding principles for complementary feeding of the breastfed child. Washington, DC:
PAHO.
———. 2013. “Process for the Promotion of Child Feeding: Field Manual.” Second Edition.
http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=20664&Itemid=.
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———. 2007. “USDA Table of Nutrient Retention Factors, Release 6.” http://www.nal.usda.gov/fnic/
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———. 2012. “USDA National Nutrient Database for Standard Reference, Release 26.”
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Appendix 1. Perceptions of Household Food Security
Occurrence questions Frequency-of-occurrencea Huehuetenango Quiché Total
Reports worrying that the food would run out before having money to buy more in the last 30 days (%)
No 47.0 15.6 31.6
Yes
Rarely 20.2 17.1 18.7
Sometimes 26.5 53.7 39.8
Often 6.3 13.6 9.9
Reports family member not being able to eat foods of animal origin such as eggs or meat because there was not enough money to buy them in the last 30 days (%)
No 66.0 31.5 49.1
Yes
Rarely 14.2 16.7 15.4
Sometimes 16.8 38.9 27.6
Often 3.0 12.8 7.8
Reports not giving foods of animal origin such as eggs or meat to children because there was not enough money to buy them in the last 30 days (%)
No 71.9 37.0 54.6
Yes
Rarely 11.4 16.0 13.7
Sometimes 13.7 36.6 25.0
Often 3.0 10.5 6.7
Reports family member eating a less-diverse diet because there was not enough money to buy a variety of foods in the last 30 days (%)
No 54.5 23.0 39.1
Yes
Rarely 17.2 15.2 16.2
Sometimes 26.9 48.3 37.3
Often 1.5 13.6 7.4
Reports family member eating foods that they did not like because there was not enough money to buy food in the last 30 days (%)
No 66.0 31.5 49.1
Yes
Rarely 18.0 16.3 17.2
Sometimes 15.4 45.1 30.0
Often 0.8 7.0 3.8
Reports family member eating less quantity of food because there was not enough money in the last 30 days (%)
No 75.8 36.2 56.4
Yes
Rarely 12.3 16.3 14.3
Sometimes 9.7 35.8 22.3
Often 2.2 11.7 6.9
Reports family member skipping meals because there was not enough money to buy food in the last 30 days (%)
No 88.4 82.5 85.5
Yes
Rarely 5.6 11.3 8.4
Sometimes 5.6 5.8 5.7
Often 0.4 0.4 0.4
a “Rarely” is once or twice in the past 30 days.
“Sometimes” is 3–10 times in the past 30 days. “Often” is more than 10 times in the past 30 days.
Source: Ballard et al. 2011.
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Appendix 2. Foods Most Commonly Consumed by Children 6–23 Monthsa,b
Name
Huehuetenango Quiché
6–8 months 9–11 months 12–23 months BF 12–23 months NBF 6–8 months 9–11 months 12–23 months BF 12–23 months NBF
% Consumed food Rank
% Consumed food Rank
% Consumed food Rank
% Consumed food Rank
% Consumed food Rank
% Consumed food Rank
% Consumed food Rank
% Consumed food Rank
Maize products 93.4 1 94.4 2 94.4 1 96.3 2 80.0 1 91.5 2 95.8 2 100.0 2
Salt 86.9 2 91.7 3 90.1 2 96.3 1 66.0 3 85.1 3 85.9 3 90.5 3
Sugar, fortified with vitamin A and iron
80.3 3 94.4 1 90.1 3 92.6 3 74.0 2 93.6 1 95.8 1 100.0 1
Tomato red, raw 57.4 7 69.4 6 73.2 4 85.2 5 58.0 4 63.8 4 74.6 4 81.0 4
Onions, tops, raw 59.0 6 77.8 4 70.4 5 85.2 4 46.0 7 59.6 5 64.8 7 61.9 8
Coffee, grain, toasted powder
62.3 4 75.0 5 69.0 6 81.5 6 42.0 8 59.6 6 74.6 5 81.0 5
Beans products 42.6 10 58.3 8 49.3 7 55.6 9 54.0 5 59.6 7 69.0 6 66.7 6
Egg, whole, raw, fresh 31.1 13 41.7 12 47.9 8 48.1 11 18.0 13 17.0 18 32.4 11 42.9 10
Oil vegetables, all types 34.4 12 52.8 9 43.7 9 44.4 13 12.0 19 25.5 12 28.2 14 57.1 9
Potatoes, without skin, raw
60.7 5 66.7 7 40.8 10 59.3 7 34.0 9 34.0 9 38.0 9 38.1 11
Dehydrated soup mix, chicken noodle or ramen noodle
44.3 8 41.7 13 32.4 13 51.9 10 48.0 6 48.9 8 64.8 8 66.7 7
Dry broth cubes, chicken or beef
44.3 9 52.8 10 40.8 11 48.1 12 18.0 15 12.8 22 21.1 17 33.3 14
Banana mature. Raw 18.0 18.0 8.3 26 25.4 14 18.5 23 22.0 10 25.5 11 21.1 16 19.0 20
Chayote (Sechium edule), raw
26.2 14 25.0 17 14.1 20 18.5 20 20.0 11 19.1 16 11.3 25 19.0 19
Chayote Sechium edule) leaves and shoots, raw
- - - - - - - - 6.0 26 27.7 10 28.2 13 33.3 12
Bread wheat, sweet (Guatemala)
14.8 20 22.2 19 22.5 16 37.0 15 12.0 18 19.1 17 33.8 10 19.0 23
Coriander, raw 34.4 11 44.4 11 33.8 12 55.6 8 12.0 16 23.4 13 21.1 15 9.5 29
a cells with “-“ represent foods that were not consumed by the target group. b shading indicates a top-10 rank for the food.
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Appendix 3. Foods Most Commonly Consumed by Pregnant Women and Lactating Women with Infants under 6 Monthsa,b
Name
Huehuetenango Quiché
Pregnant Lactating Pregnant Lactating
% Consumed food Rank
% Consumed food Rank
% Consumed food Rank
% Consumed food Rank
Salt, table 97.4 1 97.4 2 94.6 2 97.6 2
Maize products 97.4 2 100.0 1 100.0 1 100.0 1
Sugar, fortified with vitamin A and iron 89.5 3 87.2 3 94.6 3 97.6 4
Onions, tops, raw 84.2 4 76.9 5 70.3 7 80.5 6
Tomato red, raw 84.2 5 79.5 4 78.4 6 87.8 5
Coffee, grain, toasted powder 84.2 6 76.9 6 86.5 4 97.6 2
Beans products 60.5 7 61.5 7 83.8 5 61.0 7
Potatoes, without skin, raw 55.3 8 48.7 8 43.2 8 22.0 15
Dry broth cubes, chicken or beef 55.3 9 48.7 10 18.9 22 19.4 18
Oil vegetable, all types 47.4 10 35.9 13 40.5 9 36.6 11
Dehydrated soup mix, chicken noodle or ramen noodle
36.8 13 48.7 9 40.5 10 56.1 8
Egg, whole, raw, fresh 42.1 11 43.6 11 35.1 11 53.7 9
Spicy dried chili - - - - 18.9 20 43.9 10
a cells with “-“ represent foods that were not consumed by the target group. b shading indicates a top-10 rank for the food.
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Appendix 4. Food Sources of Nutrients of Children 6–23 Months
Energy
Breastfed 6–8 months Breastfed 9–11 months Breastfed 12–23 months Non-breastfed 12–23 months
Rank Food % Food % Food % Food %
1 Maize products 37.9 Maize products 31.3 Maize products 36.6 Maize products 36.9
2 Sugar 10.5 Sugar 12.8 Sugar 10.1 Sugar 11.2
3 Potatoes 6.8 Potatoes 6.5 Bread 5.7 Bread 5.2
4 Banana 4.5 Rice 5.0 Egg 4.7 Rice 4.8
5 Bread 3.6 Bread 4.3 Black beans 4.5 Incaparina 3.8
Protein
Breastfed 6–8 months Breastfed 9–11 months Breastfed 12–23 months Non-breastfed 12–23 months
Rank Food % Food % Food % Food %
1 Maize products 39.7 Maize products 29.6 Maize products 36.7 Maize products 33.9
2 Potatoes 9.5 Black beans 10.4 Egg 11.3 Egg 8.9
3 Egg 7.5 Potatoes 9.0 Black beans 10.5 Black beans 6.5
4 Black beans 6.2 Egg 7.8 Potatoes 4.7 Incaparina 6.4
5 Incaparina 4.1 Rice 3.9 Incaparina 4.0 Potatoes 5.5
Iron
Breastfed 6–8 months Breastfed 9–11 months Breastfed 12–23 months Non-breastfed 12–23 months
Rank Food % Food % Food % Food %
1 Maize products 35.2 Maize products 26.8 Maize products 31.9 Maize products 30.9
2 Incaparina 7.7 Black beans 7.4 Black beans 7.6 Incaparina 11.3
3 Potatoes 6.9 Potatoes 7.0 Incaparina 6.7 Bread 6.0
4 Bread 4.3 Incaparina 5.7 Bread 6.7 Black beans 5.7
5 Egg 3.8 Bread 5.0 Egg 6.0 Potatoes 4.1
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Zinc
Breastfed 6–8 months Breastfed 9–11 months Breastfed 12–23 months Non-breastfed 12–23 months
Rank Food % Food % Food % Food %
1 Maize products 44.3 Maize products 39.3 Maize products 42.9 Maize products 44.5
2 Incaparina 9.6 Incaparina 7.7 Incaparina 8.2 Incaparina 13.9
3 Chayote (Sechium edule)
5.4 Black beans 6.8 Egg 7.5 Rice 4.6
4 Egg 4.5 Potatoes 5.5 Black beans 6.6 Egg 4.3
5 Potatoes 4.2 Egg 5.2 Rice 3.1 Black beans 4.1
Calcium
Breastfed 6–8 months Breastfed 9–11 months Breastfed 12–23 months Non-breastfed 12–23 months
Rank Food % Food % Food % Food %
1 Maize products 49.4 Maize products 49.4 Maize products 52.4 Maize products 52.5
2 Potatoes 8.1 Potatoes 8.9 Egg 4.7 Incaparina 6.8
3 Incaparina 4.6 Incaparina 3.9 Potatoes 4.7 Potatoes 5.2
4 Egg 3.1 Egg 3.7 Incaparina 4.7 Milk 3.1
5 Black beans 3.0 Black beans 3.7 Black beans 4.4 Egg 3.0
Vitamin A
Breastfed 6–8 months Breastfed 9–11 months Breastfed 12–23 months Non-breastfed 12–23 months
Rank Food % Food % Food % Food %
1 Sugar 43.7 Sugar 58.8 Sugar 53.1 Sugar 49.7
2 Incaparina 8.0 Tomatoes 6.4 Egg 11.0 Incaparina 11.5
3 Egg 6.7 Egg 6.0 Incaparina 7.0 Egg 7.1
4 Tomatoes 5.9 Incaparina 5.8 Tomatoes 5.7 Carrots 6.8
5 Carrots 5.9 Fortified instant oats
2.6 Mustard green 3.0 Turnip leaves 4.7
Folate
Breastfed 6–8 months Breastfed 9–11 months Breastfed 12–23 months Non-breastfed 12–23 months
Rank Food % Food % Food % Food %
1 Maize products 14.5 Black bean 19.7 Black beans 22.1 Black beans 20.1
2 Chayote (Sechium edule)
10.7 Maize products 10.7 Egg 8.1 Maize products 13.0
3 Potatoes 9.7 Potatoes 9.1 Pasta 7.7 Potatoes 7.3
4 Banana 6.6 Chayote (Sechium edule)
7.5 Banana 6.7 Pasta 7.3
5 Black beans 6.4 Pasta 6.8 Maize products 10.8 Egg 6.3
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Appendix 5. Food Sources of Nutrients of Pregnant Women and Lactating Women with Infants under 6 Months
Energy
Pregnant women Lactating women
Rank Food % Food %
1 Maize products 58.4 Maize products 67.0
2 Sugar 6.4 Sugar 5.6
3 Black beans 5.7 Black beans 3.4
4 Bread 2.9 Egg 2.1
5 Potatoes 2.6 Bread 1.9
Protein
Pregnant women Lactating women
Rank Food % Food %
1 Maize products 52.4 Maize products 59.8
2 Black beans 11.8 Black beans 10.4
3 Egg 3.9 Egg 6.0
4 Potatoes 3.7 Potatoes 2.3
5 Pasta 2.4 Pasta 1.3
Iron
Pregnant women Lactating women
Rank Food % Food %
1 Maize products 50.7 Maize products 55.9
2 Black beans 10.4 Black beans 8.4
3 Bread 3.7 Egg 2.8
4 Potatoes 3.1 Incaparina 2.6
5 Incaparina 3.1 Bread 2.4
Zinc
Pregnant women Lactating women
Rank Food % Food %
1 Maize products 65.4 Maize products 71.4
2 Black beans 7.4 Black beans 4.3
3 Incaparina 4.0 Incaparina 3.5
4 Egg 2.2 Egg 3.1
5 Beef 1.8 -
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Calcium
Pregnant women Lactating women
Rank Food % Food %
1 Maize products 74.3 Maize products 77.0
2 Black beans 4.6 Black beans 2.4
3 Potatoes 2.7 Potatoes 1.7
Vitamin A
Pregnant women Lactating women
Rank Food % Food %
1 Sugar 54.8 Sugar 45.6
2 Maize products 5.9 Egg 7.7
3 Incaparina 5.3 Mustard green 7.1
4 Egg 5.0 Maize products 7.5
5 Tomatoes 3.6 Tomatoes 4.6
Folate
Pregnant women Lactating women
Rank Food % Food %
1 Black beans 35.9 Black beans 27.9
2 Maize products 18.6 Maize products 22.3
3 Potatoes 6.0 Egg 6.9
4 Pasta 6.0 Mustard green 6.4
5 - Pasta 4.1
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Appendix 6. Nutrient Intake from Complementary Foods of Breastfed Children 6–8 Months Old
Name
Huehuetenango Quiché
p-value
(mean comparison)
Breastfed 6–8 months (n = 61)
Breastfed 6–8 months (n = 50)
Mean SD Median 25th
percentile 75th
percentile Mean SD Median 25th
percentile 75th
percentile
Energy (kcal/d) 345.5 220.3 297.9 193.1 429.3 267.6 209.4 237 106.3 362.7 0.06
Protein (g/d) 10.6 7.3 8.6 4.7 14.8 7.4 6.0 6.1 2.9 9.5 0.01
Fat (g/d) 4.8 4.3 3.4 1.6 7.2 3.8 5.3 1.8 0.9 4.4 0.25
Carbohydrates (g/d) 68.0 44.0 58.4 38.5 86.1 53.2 39.6 49.4 22.8 73.3 0.07
Dietary fiber (g/d) 5.0 3.8 4.2 2.3 7.1 3.1 2.2 2.5 1.3 4.7 0.00
Calcium (mg/d) 142.6 77.4 140.3 93.6 188.0 112.4 122.1 84.7 36.5 144.0 0.12
Phosphorus (mg/d) 192.4 136.6 162.9 91.8 249.2 160.5 139.8 109.6 41.6 256.3 0.23
Iron (mg/d) 3.5 2.3 3.1 1.6 4.8 3.0 3.1 2.4 1.1 3.7 0.25
Zinc (mg/d) 1.8 1.2 1.5 0.9 2.5 1.5 2.1 1.2 0.5 1.8 0.42
Magnesium (mg/d) 21.9 20.8 16.2 6.6 28.2 26.1 25.9 15.8 7.6 35.1 0.34
Vitamin C (mg/d) 24.6 22.0 18.1 10.3 31.2 17.6 17.5 11.1 6.4 23.6 0.07
Retinol Equivalent (µg/d) 204.5 168.9 184.2 86.9 295.3 152.6 216.8 67.8 17.6 236.9 0.16
Thiamin (mg/d) 0.2 0.1 0.2 0.1 0.3 0.2 0.2 0.2 0.1 0.2 0.81
Riboflavin (mg/d) 0.3 0.6 0.1 0.1 0.3 0.7 1.0 0.2 0.1 1.2 0.01
Niacin (mg/d) 2.6 1.9 2.2 1.3 3.2 2.4 2.3 1.9 1.2 3.0 0.58
Vitamin B12 (µg/d) 0.2 0.2 0.1 0.0 0.3 0.2 0.5 0.0 0.0 0.1 0.75
Folate (µg/d) 59.3 45.8 48.0 29.0 74.6 43.8 45.5 32.6 11.5 54.7 0.08
Sodium (mg/d) 873.4 1,572.8 584.3 234.5 936.8 822.8 1,154.0 372.5 60.9 930.2 0.85
Potassium (mg/d) 399.0 343.6 312.2 155.3 529.4 328.6 304.5 259.0 109.7 432.0 0.26
Saturated fatty acids (g/d) 0.9 1.0 0.4 0.2 1.2 0.7 1.7 0.2 0.1 0.6 0.64
Mono unsaturated acids (g/d) 1.3 1.5 0.6 0.3 1.9 0.8 1.2 0.4 0.2 1.1 0.09
Poly unsaturated acids (g/d) 1.0 1.0 0.8 0.4 1.3 0.8 0.8 0.5 0.2 1.1 0.21
Cholesterol (mg/d) 49.9 80.0 2.8 0.1 93.1 28.3 66.8 0.6 0.0 4.9 0.13
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Appendix 7. Nutrient Intake from Complementary Foods of Breastfed Children 9–11 Months Old
Name
Huehuetenango Quiché
p-value
(mean comparison)
Breastfed 9–11 months (n = 36)
Breastfed 9–11 months (n = 47)
Mean SD Median 25th
percentile 75th
percentile Mean SD Median 25th
percentile 75th
percentile
Energy (kcal/d) 430.4 209.1 452.3 264.2 577.7 385.6 236.6 320.2 245.6 478.0 0.37
Protein (g/d) 13.1 7.4 12.2 7.7 18.2 10.6 6.5 8.7 6.7 13.7 0.10
Fat (g/d) 5.6 4.7 5.0 2.0 7.5 4.4 3.3 3.2 1.7 6.5 .017
Carbohydrates (g/d) 84.6 43.8 87.3 50.6 113.0 78.9 51.9 67.1 47.7 98.5 0.60
Dietary fiber (g/d) 7.6 6.3 5.7 3.4 10.0 4.7 4.1 3.8 2.2 6.1 0.01
Calcium (mg/d) 156.7 104.9 137.1 88.5 209.7 135.6 87.5 106.6 85.3 156.9 0.32
Phosphorus (mg/d) 244.5 134.0 225.7 135.0 355.2 188.0 138.3 156.2 112.7 211.6 0.10
Iron (mg/d) 4.2 2.7 3.9 2.0 5.9 4.3 3.1 3.2 2.2 6.2 0.87
Zinc (mg/d) 1.9 1.3 1.7 1.1 2.5 1.9 1.3 1.4 1.0 2.6 0.91
Magnesium (mg/d) 39.4 48.7 27.4 8.9 48.0 32.1 32.5 22.3 13.0 42.3 0.41
Vitamin C (mg/d) 48.2 82.5 23.3 7.0 51.4 21.4 18.8 16.1 5.3 32.9 0.03
Retinol Equivalent (µg/d) 221.8 191.3 167.3 99.4 285.2 237.5 268.4 137.9 58.2 297.8 0.77
Thiamin (mg/d) 0.2 0.1 0.2 0.1 0.3 0.3 0.2 0.2 0.2 0.4 0.17
Riboflavin (mg/d) 0.2 0.1 0.2 0.1 0.3 0.4 0.5 0.2 0.1 0.4 0.15
Niacin (mg/d) 2.9 2.4 2.5 1.4 3.7 2.9 1.9 2.4 1.5 4.1 0.95
Vitamin B12 (µg/d) 0.2 0.3 0.1 0.0 0.3 0.2 0.2 0.1 0.0 0.2 0.55
Folate (µg/d) 65.0 44.2 58.3 29.1 105.2 58.1 54.5 47.9 20.9 72.6 0.54
Sodium (mg/d) 1,085.8 1,824.9 660.0 259.5 1,097.8 1,164.8 2,048.1 474.0 156.7 1,072.2 0.86
Potassium (mg/d) 678.4 852.9 544.0 165.0 862.9 415.4 424.9 293.6 152.0 568.2 0.07
Saturated fatty acids (g/d) 1.0 1.1 0.8 0.3 1.6 0.8 0.8 0.5 0.3 1.3 0.30
Mono unsaturated acids (g/d) 1.7 2.0 1.0 0.5 2.6 1.2 1.3 0.9 0.4 1.6 0.23
Poly unsaturated acids (g/d) 1.0 0.6 0.9 0.6 1.3 1.0 0.7 0.9 0.6 1.2 0.88
Cholesterol (mg/d) 50.5 71.5 10.8 0.3 96.1 29.2 58.5 1.5 0.0 16.8 0.14
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Appendix 8. Nutrient Intake from Complementary Foods of Breastfed Children 12–23 Months Old
Name
Huehuetenango Quiché
p-value
(mean comparison)
Breastfed 12–23 months (n = 71)
Breastfed 12–23 months (n = 71)
Mean SD Median 25th
percentile 75th
percentile Mean SD Median 25th
percentile 75th
percentile
Energy (kcal/d) 577.8 366.9 505.9 325.4 689.7 611.7 313.0 563.5 400.3 808.6 0.55
Protein (g/d) 18.5 11.4 16.5 11.4 22.9 17.8 9.9 16.1 10.7 22.7 0.71
Fat (g/d) 8.7 7.4 6.7 3.9 11.3 7.7 5.7 6.8 3.7 10.3 0.35
Carbohydrates (g/d) 110.9 75.0 98.1 57.6 128.6 121.6 63.7 108.4 77.1 158.1 0.36
Dietary fiber (g/d) 8.9 9.2 6.5 3.9 10.4 6.6 5.1 5.1 3.3 8.0 0.06
Calcium (mg/d) 252.2 214.9 206.5 132.5 322.4 224.4 126.4 193.6 136.1 282.7 0.35
Phosphorus (mg/d) 333.9 225.9 283.9 184.3 405.9 378.9 234.6 335.8 237.6 478.5 0.25
Iron (mg/d) 7.1 9.4 5.1 2.9 8.2 6.9 5.0 5.8 4.0 8.4 0.86
Zinc (mg/d) 2.9 1.9 2.4 1.6 4.2 3.3 3.2 2.7 1.7 4.0 0.39
Magnesium (mg/d) 41.0 40.5 33.1 11.9 56.2 45.4 41.4 34.3 18.9 60.2 0.53
Vitamin C (mg/d) 54.4 137.7 26.7 14.1 48.6 31.3 31.6 22.2 10.3 38.0 0.17
Retinol Equivalent (µg/d) 419.1 1,154.7 199.6 104.1 474.1 345.0 412.6 223.8 114.4 459.4 0.61
Thiamin (mg/d) 0.4 0.3 0.3 0.2 0.5 0.5 0.3 0.4 0.2 0.6 0.09
Riboflavin (mg/d) 0.4 0.5 0.3 0.2 0.6 1.6 2.4 0.5 0.3 2.5 < .0001
Niacin (mg/d) 5.4 13.6 3.3 2.0 4.5 5.1 4.3 4.2 2.5 6.2 0.85
Vitamin B12 (µg/d) 0.4 0.4 0.3 0.0 0.6 0.3 0.4 0.1 0.0 0.6 0.43
Folate (µg/d) 138.4 408.3 77.0 47.4 111.9 109.5 103.3 87.2 48.6 135.0 0.56
Sodium (mg/d) 1,247.3 1,762.4 656.6 325.0 1,586.5 1,482.0 1,359.7 1,139.4 404.8 1,820.7 0.38
Potassium (mg/d) 753.3 902.2 550.4 264.0 936.6 590.5 449.4 549.5 221.7 801.8 0.18
Saturated fatty acids (g/d) 1.8 2.1 1.2 0.3 2.7 1.4 1.4 1.1 0.3 2.0 0.20
Mono unsaturated acids (g/d) 2.5 2.6 1.7 0.6 3.0 2.2 2.3 1.5 0.6 3.1 0.48
Poly unsaturated acids (g/d) 1.6 1.4 1.1 0.7 2.0 1.7 1.3 1.3 0.8 2.2 0.81
Cholesterol (mg/d) 91.1 106.3 27.6 0.2 171.7 72.7 105.9 9.1 1.6 143.4 0.30
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Appendix 9. Nutrient Intake of Non-Breastfed Children 12–23 Months Old
Name
Huehuetenango Quiché
p-value
(mean comparison)
Non-breastfed 12–23 months (n = 27)
Non-breastfed 12–23 months (n = 21)
Mean SD Median 25th
percentile 75th
percentile Mean SD Median 25th
percentile 75th
percentile
Energy (kcal/d) 924.3 546.2 815.4 518.2 1,207.6 1,048.3 515.4 1,030.0 618.9 1,345.4 0.55
Protein (g/d) 25.6 13.1 25.3 15.6 35.3 30.9 19.0 28.1 20.8 36.4 0.71
Fat (g/d) 12.2 7.8 11.4 8.0 13.9 12.7 11.6 10.3 5.9 14.8 0.35
Carbohydrates (g/d) 184.9 117.3 158.3 107.4 255.8 209.2 97.6 201.3 131.5 272.2 0.36
Dietary fiber (g/d) 12.0 9.2 9.3 6.8 16.0 12.4 8.8 8.4 6.5 20.5 0.06
Calcium (mg/d) 356.4 170.2 343.8 255.9 458.6 420.8 236.1 359.9 274.0 546.0 0.35
Phosphorus (mg/d) 497.9 279.9 435.7 313.4 592.7 711.4 467.7 642.1 353.1 1,224.3 0.25
Iron (mg/d) 9.2 5.3 7.9 5.6 13.7 12.3 7.6 9.8 8.4 16.0 0.86
Zinc (mg/d) 4.7 3.0 3.8 2.4 7.1 6.5 4.8 5.6 3.7 7.4 0.39
Magnesium (mg/d) 68.9 67.8 51.6 26.8 92.1 74.2 65.5 55.6 33.6 91.6 0.53
Vitamin C (mg/d) 57.1 59.7 44.6 13.0 79.0 41.9 31.7 34.1 18.1 51.6 0.17
Retinol Equivalent (µg/d) 566.6 472.1 320.0 234.6 971.6 682.1 732.7 385.0 285.1 510.8 0.61
Thiamin (mg/d) 0.6 0.4 0.6 0.3 0.7 0.8 0.4 0.7 0.6 0.9 0.09
Riboflavin (mg/d) 0.9 2.1 0.4 0.3 0.8 3.3 3.9 1.1 0.5 5.1 0.00
Niacin (mg/d) 6.1 3.9 4.9 3.4 8.2 8.9 6.0 7.0 5.8 8.9 0.85
Vitamin B12 (µg/d) 0.5 0.6 0.4 0.0 0.8 0.7 1.1 0.2 0.1 0.6 0.43
Folate (µg/d) 120.1 82.1 109.4 62.4 149.1 138.1 99.6 102.7 70.2 190.0 0.21
Sodium (mg/d) 1,286.5 1,033.0 950.1 608.1 1,851.6 1,568.0 1,489.3 1,343.1 390.2 2,109.7 0.38
Potassium (mg/d) 910.8 943.4 591.5 348.8 1,068.6 950.8 886.5 780.3 360.5 1,034.5 0.18
Saturated fatty acids (g/d) 2.4 2.2 1.8 1.2 2.9 2.4 3.0 1.7 1.2 2.4 0.20
Mono unsaturated acids (g/d) 3.4 2.8 3.2 1.9 4.2 4.0 4.8 2.6 1.6 3.5 0.48
Poly unsaturated acids (g/d) 2.5 2.0 2.3 1.3 2.9 2.8 2.0 2.3 1.3 3.7 0.81
Cholesterol (mg/d) 100.5 114.8 57.3 3.5 179.3 79.6 101.4 11.1 3.9 168.7 0.30
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Appendix 10. Nutrient Intake of Pregnant Women
Name
Huehuetenango Quiché
p-value
(mean comparison)
Pregnant (n = 38)
Pregnant (n = 37)
Mean SD Median 25th
percentile 75th
percentile Mean SD Median 25th
percentile 75th
percentile
Energy (kcal/d) 2,177.9 791.6 2,291.4 1,700.5 2,657.1 2,254.5 992.7 2,129.7 1,567.2 2,692.4 0.71
Protein (g/d) 68.2 28.9 69.2 54.4 88.4 67.8 37.3 58.7 42.9 71.0 0.96
Fat (g/d) 26.2 23.5 19.8 12.9 34.5 21.9 17.2 16.7 12.7 27.0 0.37
Carbohydrates (g/d) 433.5 163.1 455.8 333.3 557.2 462.0 190.4 447.9 327.1 551.7 0.49
Dietary fiber (g/d) 36.9 18.1 35.7 20.4 53.0 35.3 23.5 34.8 18.0 44.8 0.75
Calcium (mg/d) 997.7 378.7 1,030.7 707.2 1,177.2 1,121.4 421.3 1,029.9 844.0 1,398.6 0.18
Phosphorus (mg/d) 1,354.9 642.2 1,263.9 1,040.9 1,656.6 1,982.1 1,154.6 1,602.9 1,187.4 2,559.0 0.00
Iron (mg/d) 19.0 7.3 17.7 15.6 24.2 24.5 14.1 22.2 17.9 24.7 0.04
Zinc (mg/d) 11.4 4.7 11.5 8.6 14.3 12.8 7.1 11.5 7.8 14.2 0.31
Magnesium (mg/d) 104.8 81.6 96.4 37.2 142.6 130.5 177.6 72.0 57.4 169.0 0.42
Vitamin C (mg/d) 103.3 95.2 74.5 40.8 142.4 58.9 44.0 57.4 17.4 81.1 0.01
Retinol Equivalent (µg/d) 739.4 387.5 741.8 456.6 962.4 685.3 771.5 467.4 284.6 712.6 0.70
Thiamin (mg/d) 1.2 0.5 1.1 0.9 1.5 1.6 2.1 1.2 1.0 1.5 0.22
Riboflavin (mg/d) 2.1 6.7 1.0 0.7 1.2 10.7 14.1 1.5 0.7 15.4 0.00
Niacin (mg/d) 14.5 7.1 13.8 10.3 18.6 17.0 15.7 13.2 9.5 17.3 0.37
Vitamin B12 (µg/d) 0.8 1.2 0.5 0.0 0.9 0.9 2.0 0.3 0.0 0.6 0.91
Folate (µg/d) 237.3 139.6 219.0 145.0 293.4 373.8 590.4 237.5 179.9 375.3 0.73
Sodium (mg/d) 3,745.2 3,231.4 3,134.0 1,605.6 4,611.9 2,396.5 1,977.7 1,718.5 1,001.0 3,954.2 0.03
Potassium (mg/d) 1,776.8 1,352.7 1,412.6 804.4 2,583.9 1,558.6 1,375.8 1,059.4 645.4 1,914.8 0.49
Saturated fatty acids (g/d) 5.3 7.0 3.0 1.5 6.7 3.3 3.8 1.9 1.0 3.8 0.12
Mono unsaturated acids (g/d) 8.5 10.0 6.1 3.2 10.8 6.5 7.2 4.8 2.1 7.7 0.32
Poly unsaturated acids (g/d) 7.3 4.8 6.8 3.8 9.2 6.9 3.8 6.6 4.1 9.0 0.71
Cholesterol (mg/d) 175.2 251.4 86.4 2.8 236.8 108.4 169.6 4.9 0.1 192.1 0.18
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Appendix 11. Nutrient Intake of Lactating Women with Infants under 6 Months
Name
Huehuetenango Quiché
p-value
(mean comparison)
Lactating (n = 39)
Lactating (n = 41)
Mean SD Median 25th
percentile 75th
percentile Mean SD Median 25th
percentile 75th
percentile
Energy (kcal/d) 2,243.8 837.7 2,136.1 1,634.6 2,748.4 2,729.8 835.3 2,657.8 2,188.5 3,090.7 0.01
Protein (g/d) 70.8 33.4 66.9 46.9 89.8 77.0 22.4 75.6 62.9 87.2 0.32
Fat (g/d) 24.7 18.3 19.2 10.6 34.9 27.7 15.7 24.0 17.6 30.7 0.43
Carbohydrates (g/d) 451.5 162.0 434.8 348.2 546.4 562.7 170.8 558.0 459.7 671.5 0.00
Dietary fiber (g/d) 43.0 21.5 40.5 30.6 50.6 35.2 18.5 38.3 20.2 51.5 0.08
Calcium (mg/d) 1,170.9 489.7 1,162.2 838.6 1,410.1 1376.0 411.3 1,337.1 1,043.5 1,613.9 0.05
Phosphorus (mg/d) 1,419.4 602.1 1,380.0 1,004.8 1,707.4 3,006.6 2,134.2 2,052.6 1,363.7 4,638.7 0.00
Iron (mg/d) 21.2 11.9 19.4 13.3 23.0 27.8 10.7 27.1 20.8 33.8 0.01
Zinc (mg/d) 12.5 5.9 12.0 8.4 14.0 15.1 4.9 14.5 12.3 17.8 0.03
Magnesium (mg/d) 68.9 72.5 45.8 13.3 104.4 93.3 66.8 90.2 32.0 123.7 0.12
Vitamin C (mg/d) 101.8 94.9 69.3 42.5 123.3 63.9 54.7 43.5 23.0 88.7 0.03
Retinol Equivalent (µg/d) 974.3 2,269.4 512.1 283.3 802.6 897.8 795.7 740.5 378.5 1,199.4 0.84
Thiamin (mg/d) 1.3 0.6 1.2 0.8 1.6 1.5 0.5 1.5 1.2 1.8 0.05
Riboflavin (mg/d) 1.1 1.0 0.9 0.6 1.1 22.4 28.1 1.5 0.9 38.3 0.00
Niacin (mg/d) 14.4 7.0 12.4 9.4 17.7 19.5 7.9 18.9 13.8 23.6 0.00
Vitamin B12 (µg/d) 4.0 20.3 0.5 0.0 1.0 0.8 1.2 0.5 0.0 0.8 0.32
Folate (µg/d) 279.0 179.8 218.9 152.4 349.0 262.8 134.9 223.4 162.5 323.3 0.04
Sodium (mg/d) 2,744.3 1,927.8 2,267.5 1,546.2 2,839.5 3,249.0 1,931.0 3,463.9 1,794.2 4,035.4 0.25
Potassium (mg/d) 1,644.3 1,425.5 1,178.2 648.8 2,233.5 1,288.5 947.0 1,141.3 610.9 1,595.2 0.19
Saturated fatty acids (g/d) 4.5 5.0 3.0 1.3 5.8 4.3 4.7 2.7 2.2 4.5 0.89
Mono unsaturated acids (g/d) 8.0 8.3 5.5 2.9 8.4 7.9 6.6 5.9 4.3 8.3 0.96
Poly unsaturated acids (g/d) 7.5 3.6 7.0 4.7 9.3 8.5 4.7 7.7 5.0 10.6 0.31
Cholesterol (mg/d) 170.4 208.5 91.3 2.3 250.2 181.9 215.4 160.1 3.9 229.2 0.81
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Appendix 12. Food Lists Entered into Optifood: Cost per 100 g of the Edible Portion, Median Serving Sizes, Number of Consumers, and Maximum Number of Times per Week It Could Be Consumed (Freq) by Target Groupa
Foods
Cost Breastfed
6–8 months Breastfed
9–11 months Breastfed
12–23 months Non-breastfed 12–23 months Pregnant Lactating
GTQ/ 100 g
Serv. (g) n Freq
Serv. (g) n Freq
Serv. (g) n Freq
Serv. (g) n Freq
Serv. (g) n Freq
Serv. (g) n Freq
Tortilla, yellowb .7 13 12 14 19 16 14 22 36 14 37 7 14 185 21 14 237 18 14
Tortilla, whiteb .7 16 74 14 19 58 14 20 91 14 50 24 21 205 53 14 240 59 14
Incaparina, powderb 1.96 9 20 7 10 14 7 20 20 7 24 10 7 26 11 7 29 12 7
Tamalito, white/yellowb .7 35 12 7 45 2 14 35 23 7 66 8 14 207 17 10 414 19 10
Corn dough, whiteb 1.1 18 24 14 20 21 7 22 33 10 48 9 14 58 14 14 72 22 14
Corn dough, yellowb 1.1 24 9 14 33 10 7 58 3 7 121 7 14 220 6 7
Corn, whiteb .5 13 31 14 17 16 7 23 39 7 31 14 14 50 22 10 51 28 10
Corn, white/blackb .5 54 2 2
Corn, yellowb .5 22 13 14 52 2 7 66 5 7 61 7 10
Pasta, commercialb 1.27 7 22 1 9 17 7 17 37 7 24 12 3 50 20 5 25 17 7
Oats, instant, fortifiedb 2.18 7 5 1 9 5 14 8 9 14 4 3 3 13 3 7 14 3 7
Oats, not fortifiedb 1 8 10 4 8 15 7 7 20 7 20 7 3 24 10 7 14 8 7
Pinol, plain (atole) b 1.07 38 4 14
Rice, whiteb 1.1 9 17 7 18 23 3 24 32 4 29 13 3 62 16 7 46 16 3
Cereal Corazon de Trigo 1.5 28 2 10
Bread, white 1.37 37 15 7 25 15 7 32 40 7 53 10 7 65 21 7 72 12 7
Vegetable oil 2.33 1 27 4 1 31 7 1 52 4 1 20 3 2 35 4 2 29 5
Sugar .9 8 86 7 9 78 7 12 132 7 22 35 7 33 69 7 29 74 7
Coffee, toasted powder 2.79 0.5 59 7 0.4 55 7 1 102 7 1 30 7 2 64 7 2 70 7
Potatoes .37 55 55 7 57 40 7 58 56 7 75 18 7 120 38 7 168 28 7
Tomato, red .45 10 64 7 12 55 7 25 105 4 28 30 4 44 61 7 52 67 7
Tree tomato 1.54 9 5 4 15 2 2 52 6 4
Husk tomato .43 29 2 5
Onion, bulb and tops .64 2 7 3 4 14 3 16 3 3 10 11 4 32 7 7
Onion bulbs-cebolla .47 3 59 7 4 56 5 7 96 4 8 25 4 15 58 7 15 63 7
Amaranth leavesd .42 15 2 3 43 2 3 20 5 3 18 1 2 59 4 7 69 6 7
Turnip greens .58 9 6 4 29 4 4 62 4 2 58 4 3
Nightshade leavesd,e .86 27 4 4 28 3 5 21 10 4 25 2 7 55 10 7 64 9 7
Crotalaria, leaf and shootsd 1.15 5 1 5 28 2 2 95 2 2 80 2 7
Chayote (Sechium edule), leaves and shoots
.62 16 6 6 31 13 3 31 21 4 56 7 3 112 9 4 110 14 4
Pumpkin, leavesd .26 22 1 2 33 3 3 64 1 3 133 3 4
Cabbage .29 141 2 3 103 5 2
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Breastfed Breastfed Breastfed Non-breastfed
Foods
Cost 6–8 months 9–11 months 12–23 months 12–23 months Pregnant Lactating
GTQ/ 100 g
Serv. (g) n Freq
Serv. (g) n Freq
Serv. (g) n Freq
Serv. (g) n Freq
Serv. (g) n Freq
Serv. (g) n Freq
Chayote (Sechium edule) .4 54 23 4 45 18 4 66 17 5 50 7 3 179 12 3 144 10 4
Carrots .67 13 15 5 14 5 4 35 8 7 34 8 3 102 6 2 50 5 2 dPumpkin .8 174 1 4 86 1 2 460 1 2 450 2 1 401 1 4
Beans, snap .56 109 2 3 dPeas, green 3.38 22 1 0.2 46 1 1
dPlantain .64 78 5 3 311 3 3 127 3 1 428 3 3 250 4 7 200 3 3 dOrange .39 115 2 2 48 2 7 171 7 7 161 1 3 149 5 7 204 4 3
Banana .93 64 22 7 74 15 7 110 33 7 123 7 4 169 8 7 173 7 7
Banana datil .8 35 6 7 46 12 7 164 2 3
Lemon .96 1 6 7 4 14 7 4 19 7 11 5 7 15 14 7 12 11 7
Apple .42 86 5 3 76 10 7 140 6 7
Milk, powder 8.13 2 11 7 3 10 7 8 20 7 5 9 7 10 10 7 5 6 7 dCheese 4.07 8 1 1 25 1 1 20 2 1 4 1 0.5 77 1 1 230 1 1
Egg, whole 2.87 30 27 5 27 23 5 52 58 7 47 16 4 58 29 4 60 40 7
Egg, yolk 8.6 18 1 1
Chicken 3.32 14 7 2 52 1 2 38 2 1 178 6 2 173 5 2
Lamb 4.7 43 1 0.5 115 1 1
Frankfurter, beef and pork 2.6 3 1 0.5 18 3 2 180 1 1 40 1 2 Lamb liverc 2.8 90 0 1 90 1 1
Black beans 1 24 6 3 26 11 4 31 29 4 61 7 3 115 31 3 122 23 7
Black beans, dry 1.2 23 14 7 19 14 3 29 26 7 69 23 5 58 25 4 dProtemas, soy protein 1.36 4 1 1
Bean broth .1 29 33 7 21 24 4 36 34 4 41 10 7
Chicken broth, powder 8.33 1 35 4 0.6 24 5 1 43 4 1 16 4 2 28 5 2 27 7
Chicken noodle soup, dehydrated
3.33 1 50 5 2 35 4 4 70 4 5 18 4 6 26 7 5 41 7
Beef broth, powder 10 1 2 3
Ramen noodle soup, dehydrated
2.5 13 3 2
Beverage, concentrate 6.92 1 6 7 4 5 7
Orange, powder, drink 3 1 5 7
a Serving sizes were expressed in g/day for foods from all food groups except those in the “Grains and Grain Products” food group. b Serving size was expressed in in g/meal. c Liver was added to the food list for pregnant women, even though it was not consumed by any pregnant woman, to help meet vitamin B12 requirements. d Consumed by < 5% for all target groups. e Hierba mora (Solanum tuberosum).
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Appendix 13. The Food Group Constraints Used in the Models (servings/week) for Each Target Group
Food group
Breastfed 6–8 months
Breastfed 9–11 months
Breastfed 12–23 months
Non-breastfed 12–23 months Pregnant Lactating
Low serv/ week
Avera serv/ week
High serv/ week
Low serv/ week
Avera serv/ week
High serv/ week
Low serv/ week
Avera serv/ week
High serv/ week
Low serv/ week
Avera serv/ week
High serv/ week
Low serv/ week
Avera serv/ week
High serv/ week
Low serv/ week
Avera serv/ week
High serv/ week
Added sugars 3 6 7 5 7 8 5 7 8 5 7 8 5 7 8 5 7 8
Added fats 0 1 7 0 1 7 0 1 7 0 6 7 0 1 7 0 1 7
Fruits 0 1 7 0 1 7 0 4 14 0 1 7 0 4 14 0 1 7
Vegetables 0 14 28 0 14 28 7 14 28 7 21 35 7 21 28 14 21 28
Dairy products 0 1 7 0 1 7 0 1 7 0 1 7 0 1 7 0 1 7
Legumes 0 1 7 0 1 7 0 1 7 0 1 7 0 7 14 0 7 8
Meat, poultry, eggs
0 1 7 0 1 7 0 1 7 0 7 8 0 4 14 0 7 8
Roots 0 6 7 0 1 7 0 1 7 0 4 7 0 7 14 0 1 7
Grains 7 28 42 7 28 42 14 28 49 21 35 56 21 28 49 28 35 49
Bakery, breakfast cereal
0 1 7 0 1 7 0 1 7 0 1 7 0 1 7 0 1 7
Beverages 0 7 14 0 7 14 0 7 14 6 7 14 6 7 14 6 7 14
Mixed foods 0 7 14 0 7 14 0 7 14 0 11 14 0 7 14 0 7 14
Staples 7 14 21 7 14 21 7 21 28 7 21 28 14 21 28 20 21 28
Snacks 0 1 7 0 1 14 0 7 14 0 1 14 0 1 14 0 1 7
a The “average” food pattern is defined by the median or 50th percentile of consumption observed by the target group.
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Appendix 14. The Food Subgroup Constraints Used in the Models (servings/week) for Each Target Group
Breastfed 6–8 months Breastfed 9–11 months Breastfed 12–23 months Non-breastfed 12–23 months Pregnant Lactating
Food subgroups Low
serv/week High
serv/week Low
serv/week High
serv/week Low
serv/week High
serv/week Low
serv/week High
serv/w Low
serv/week High
serv/week Low
serv/week High
serv/week
Vegetable oil, unfortified 0 7 0 7 0 7 0 7 0 7 0 7
Sugar (fortified) 5 7 5 7 5 8 5 8 5 8 5 8
Enriched/fortified bread 0 7 0 7 0 7 0 7 0 7 0 7
Coffee 0 7 0 7 0 7 0 7 0 7 0 7
Juices 0 7
Sugar beverages 0 1 0 7 0 7
Broths 0 7 0 7 0 7 0 14 0 7 0 7
Soups 0 7 0 1 0 7 0 7 0 7 0 7
Cheese 0 1 0 7 0 1 0 1 0 1 0 7
Milk, powder (unfortified) 0 7 0 7 0 7 0 7 0 7 0 7
Other fruit 0 7 0 7 0 7 0 7 0 7 0 7
Vitamin C fruit 0 1 0 7 0 7 0 7 0 7 0 7
Enriched/fortified grains 0 1 0 14 0 3 0 5 0 7
Atole 0 14 0 14 0 14 0 14 0 14 0 14
Refined grains 0 7 0 3 0 4 0 3 0 7 0 3
Whole grains 7 35 7 35 7 42 14 42 21 35 21 42
Cooked beans 0 7 0 7 0 7 0 7 0 14 0 7
Soy products 0 1
Eggs 0 7 0 7 0 7 0 7 0 7 0 7
Organ meat 0 1
Poultry 0 1 0 1 0 7 0 7 0 7
Processed meat 0 1 0 1 0 1 0 1
Red meat 0 1 0 1
Other root vegetable 0 7 0 7 0 7 0 7 0 14 0 7
Condiment vegetables 0 7 0 7 0 7 0 7 0 7 0 7
Other vegetables 0 4 0 4 0 4 0 7 0 7 0 7
GLVs 0 7 0 7 0 7 0 7 0 7 0 7
Vitamin A other vegetable 0 7 0 1 0 1 0 7 0 7 0 7
Vitamin C vegetable 0 14 0 14 0 14 0 14 0 14 0 14
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Appendix 15. INCAP Recommended Dietary Allowances and Adequate Intakes (INCAP 2012)
Calciuma
mg/day Vitamin C
mg/day Thiamin mg/day
Riboflavin mg/day
Niacin mg/day
B6 mg/day
Folate µg DFEc/day
B12 µg/day
Vitamin A µg RE/day
Irone
mg/day Zinc
mg/day Energy
kcal Protein
g
Children 6–9 months
400 50b 0.3 0.4 4 0.3 75 0.5 450d 9f 6.3 620.0 14
Children 9–11 months
400 50b 0.3 0.4 4 0.3 75 0.5 450d 9f 6.3 700.0 16
Children 12–23 months
500 15 0.4 0.5 6 0.5 150 0.9 210d 14 4.6 850.0 16
Pregnant women 1,000 75 1.4 1.4 18 1.9 600 2.6 500 n/ag 20.2 2,467.5 88
Lactating women 1,000 100 1.3 1.6 17 2.0 500 2.8 825 31.2 22.6 2,900.0 87
a Calcium values refer to adequate intake (AI) values. b Vitamin C values for children 6–11 months refer to the AI values. c Dietary Folate Equivalent
d Vitamin A values for children 6–23 months refer to AI values. e Iron values for children 12–23 months, pregnant women, and lactating women are for a 5% level of bioavailability of iron in diet. f Iron values for children 6–11 months are for a 10% level of bioavailability of iron in diet. There is no INCAP RDA for iron for children 6–11 months at 5% level of bioavailability of iron in diet. Note
that the bioavailability of dietary iron during this period varies greatly. The WHO/FAO 2004 RNI for 5% level of bioavailability of iron in the diet for children 6–11 months is 18.6 mg/day. g INCAP does not provide values for dietary iron requirements in pregnant women because the iron balance in pregnancy depends on the properties of the diet and the amounts of stored iron. The
low bioavailability of iron in the diet and probability of a high prevalence of low iron stores make it unlikely that pregnant women in Guatemala can meet their daily requirements for iron.
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Appendix 16. Module 3, Stage 1: Formulation of FBRs for Breastfed Children 6–8 Months Old with Incaparina and Fortified Instant Oats – Selection of the Key Messages
Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
89 94
100 100
136 124
141 139
108 117
139 155
182 173
109 106
117 123
74 78
63 64
1.7 1.8
Maximizeda 97 138 152 166 135 245 213 146 144 80 66 3.0
No Recommendations 48 50 49 58 31 36 42 51 75 14 22 0.8
1 2 3 4 5 6 7 8 9
10 11 12 13 14
Veg28 Veg21 GLV7 Dairy7 MPE7 MPE3 Legume7 Staple21 Staple14 Incaparina7 Fort oats7 Potato7 Potato4 Fruit7
51 49 48 52 51 49 50 56 52 54 54 52 50 48
64 56 50 50 50 50 50 50 50 50 50 59 54 60
55 52 49 50 50 50 56 53 50 90 69 50 49 49
64 60 58 63 83 65 58 58 58 94 77 61 59 64
36 34 31 31 34 31 33 36 33 73 53 43 36 38
54 45 36 37 46 39 45 52 42 36 67 75 53
100
67 47 42 43 54 46 79 42 42 66 65 49 45 54
52 51 51 63
107 70 51 51 51 71 51 52 51 52
89 78 75 76 84 78 75 76 75 79 92 75 75 75
17 15 14 14 16 14 17 15 14 26 34 16 14 14
24 22 22 23 26 23 24 26 24 44 24 25 23 22
1.0 0.9 0.8 0.9 1.6 1.1 0.8 0.8 0.8 0.9 0.8 0.9 0.9 1.2
15 10-11 59 50 110 113 96 67 89 71 96 48 46 0.9
16 17
8-10-11 9-10-11
68 64
50 50
113 111
113 113
101 98
85 75
89 89
71 71
96 96
50 47
50 48
0.9 0.9
18 19 20 21
1-8-10-11 1-9-10-11 2-8-10-11 2-9-10-11
72 67 70 65
64 64 56 56
119 117 116 115
119 119 115 115
107 104 104 101
104 93 94 84
113 113 93 93
72 72 71 71
111 110 100 99
54 51 51 49
52 50 50 48
1.1 1.1 1.0 1.0
22 23 24 25 26 27
1-8-10-11-12 1-9-10-11-12 2-8-10-11-12 2-9-10-11-12 1-8-10-11-4 1-9-10-11-4
76 71 74 69 74 69
74 74 65 65 69 69
120 117 118 115 119 117
122 122 118 118 121 121
120 117 117 114 114 111
144 134 136 126 127 117
120 120 99 99
116 116
73 72 72 72 72 72
111 110 100 99
111 110
57 54 54 52 55 52
55 53 53 51 54 51
1.2 1.2 1.1 1.1 1.2 1.2
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Calcium % RDA
Vitamin % RDA
C Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin % RDA
A Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
89 94
100 100
136 124
141 139
108 117
139 155
182 173
109 106
117 123
74 78
63 64
1.7 1.8
Maximizeda 97 138 152 166 135 245 213 146 144 80 66 3.0
No Recommendations 48 50 49 58 31 36 42 51 75 14 22 0.8
28293031 32 33 34 35 36 37 38
1-8-10-11-12-5 1-9-10-11-12-5 2-9-10-11-12-5 1-8-10-11-12-6 1-9-10-11-12-6 2-9-10-11-12-6 1-8-10-11-12-7 1-9-10-11-12-7 2-9-10-11-12-7 1-9-10-11-13-7 1-9-10-11-12-leg3
79 74 72 77 72 70 78 73 71 71 72
74 74 65 74 74 65 74 74 65 69 74
123 119 116 121 117 115 128 124 122 124 120
150 148 144 130 130 126 124 123 119 122 123
123 120 117 120 117 114 123 119 117 114 118
156 146 138 149 139 130 155 145 136 127 139
133 132 112 123 123 103 157 157 137 154 136
129 129 128 91 91 91 73 73 72 72 72
120 119 108 114 113 102 111 110 99
110 110
61 58 56 58 55 53 61 58 56 57 56
59 56 55 56 54 52 57 55 53 53 54
2.0 2.0 1.9 1.5 1.5 1.4 1.2 1.2 1.1 1.2 1.2
39 40 41 42 43
1-9-10-11-12-5-7 1-8-10-11-12-5-7 2-8-10-11-12-5-7 2-9-10-11-12-5-7 1-8-10-11-12-6-7
76 82 79 74 79
74 75 65 65 74
128 133 130 125 129
150 152 147 146 132
122 126 123 120 123
157 168 158 148 160
170 171 150 150 161
129 129 129 128 92
119 126 110 108 114
62 67 63 60 62
58 61 59 56 58
2.0 2.0 1.9 1.9 1.5
a Refers to maximized diet, that is, a diet following the final set of FBRs in which nutrient intake is maximized.
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Appendix 17. Module 3, Stage 1: Formulation of FBRs for Breastfed Children 9–11 Months Old with Incaparina and Fortified Instant Oats – Selection of the Key Messages
Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
112 114
114 117
158 165
176 176
138 130
189 185
210 210
140 138
152 146
100 100
76 77
2.7 2.6
Maximizeda 125 203 205 207 203 374 271 146 195 136 78 3.6
No Recommendations 47 49 57 63 41 54 45 51 81 16 23 1.1
1 2 3 4 5 6 7 8 9
10 11 12 13 14
Veg21 GLV7 Dairy7 MPE7 MPE3 Beans7 Staple14 Staple21 Incap7 Fort oats7 Potato7 Potato4 Veg28 Fruit7
49 58 54 50 48 51 53 60 54 55 54 50 59 47
63 72 49 49 49 49 49 49 49 49 59 55 89 53
63 64 58 58 57 64 59 61
103 82 58 57 69 57
67 81 71 86 70 64 63 63
103 87 66 65 84 63
45 45 40 40 40 40 41 42 84 67 51 46 50 40
65 85 54 57 55 61 59 68 54 94 91 75 95 55
57 63 46 52 47 83 45 45 70 73 51 48 91 46
52 52 70
101 67 51 51 51 73 51 52 52 52 51
84 99 83 88 83 81 81 82 86
102 81 81
102 81
19 38 16 19 17 22 17 20 31 44 23 18 39 16
24 24 24 26 24 26 25 28 47 26 30 24 27 23
1.3 1.2 1.3 1.7 1.3 1.1 1.1 1.1 1.2 1.2 1.2 1.1 1.4 1.1
15 9-10 62 49 128 127 113 94 98 73 107 58 50 1.3
16 17 18
1-9-10 2-9-10 9-10-11
63 73 68
63 73 59
133 135 128
131 144 130
118 118 124
105 124 130
110 116 105
74 73 74
110 125 107
61 80 61
52 52 55
1.5 1.4 1.4
19 20 21 22 23 24
2-9-10-7 2-9-10-8 2-9-10-6 2-9-10-5 2-9-10-4 2-9-10-11
78 73 76 74 75 78
72 79 73 72 72 82
137 138 142 135 136 135
144 146 145 151 167 147
120 121 120 118 118 130
132 129 133 126 129 163
116 119 156 119 125 124
73 74 74 89
123 74
125 126 125 127 132 125
80 81 86 80 82 82
55 52 55 53 55 56
1.4 1.5 1.4 1.7 2.0 1.5
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Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
112 114
114 117
158 165
176 176
138 130
189 185
210 210
140 138
152 146
100 100
76 77
2.7 2.6
Maximizeda 125 203 205 207 203 374 271 146 195 136 78 3.6
No Recommendations 47 49 57 63 41 54 45 51 81 16 23 1.1
25 26 27 28 29 30 31 32
2-9-10-4-6 2-9-10-5-6 2-9-10-4-11 2-9-10-5-11 2-9-10-6–11 2-9-10-5-8 2-9-10-6–8 2-9-10-11-8
79 77 80 78 81 86 89 90
73 73 82 82 83 72 73 82
143 142 136 135 142 139 146 139
169 152 171 154 148 151 145 147
120 120 130 130 133 124 127 137
139 135 169 165 173 143 153 182
165 158 133 126 164 119 156 124
123 90
124 90 74 89 74 74
132 127 132 127 125 128 126 126
89 86 85 83 88 85 90 86
59 57 59 58 59 59 62 61
2.0 1.7 2.1 1.8 1.5 1.7 1.4 1.5
33 34 35 36 37 38 39 40
2-9-10-5-6–11 2-9-10-5-6–8 2-9-10-6–8-11 2-9-10-5-8-11 2-9-10-4-6–8 1-9-10-6–8-11 1-9-10-5-6–11 1-9-10-5-6–8
82 90 93 91 92 84 72 80
83 73 83 82 73 73 73 63
142 147 148 140 149 147 141 146
156 152 149 154 169 135 142 138
133 127 141 137 127 140 132 127
175 157 195 186 162 176 156 137
166 159 164 126 166 158 161 153
91 90 75 91
124 75 91 90
127 128 126 128 133 111 112 113
89 92 93 88 94 74 70 73
61 63 64 62 66 64 61 63
1.8 1.7 1.5 1.8 2.0 1.6 1.8 1.7
41 42 43
2-9-10-4-6–8-11 9-10-4-6–8-11-13 9-10-4-6–8-11-13
96 97 95
83 100 100
151 159 156
174 180 161
141 147 147
205 219 212
174 206 197
125 129 92
133 137 132
98 100 97
68 72 69
2.2 2.4 2.0
a Refers to maximized diet, that is, a diet following the final set of FBRs in which nutrient intake is maximized.
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Appendix 18. Module 3, Stage 1: Formulation of FBRs for Breastfed Children 12–23 Months Old with Incaparina and Fortified Instant Oats – Selection of the Key Messages
Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
100 100
364 394
164 179
192 212
120 139
102 134
126 147
120 121
229 261
72 90
147 155
4.1 4.3
Maximizeda 121 1136 246 249 177 262 199 152 318 92 159 6.0
No Recommendations 44 163 57 58 32 42 28 28 126 16 43 1.5
Fruit7 Veg28 Veg21 MPE7 MPE3 Beans7 GLV7 Dairy7 Incap7 Fort oats7 Potato7 Potato4 Staple21
44 47 44 46 44 46 46 56 53 48 46 44 51
177 266 208 163 163 164 179 167 163 163 197 182 163
57 66 62 58 58 63 60 59
124 73 58 57 59
58 70 63 94 70 58 66 73
122 76 60 59 58
32 40 36 32 32 32 34 32 91 48 39 36 34
43 62 52 46 43 47 53 47 47 63 64 55 50
28 53 34 35 30 52 34 28 53 41 31 30 28
28 29 29 86 50 28 28 54 52 28 29 28 28
126 153 132 147 133 126 142 132 140 154 126 126 128
16 21 18 17 16 19 20 16 32 30 17 16 17
43 50 44 50 45 48 43 46
107 46 46 44 48
1.6 1.9 1.7 2.6 1.9 1.5 1.6 2.0 1.7 1.7 1.6 1.6 1.5
11-12 58 163 141 140 108 63 66 52 169 48 110 1.9
11-12-15 2-11-12 3-11-12 8-11-12 10-11-12 4-11-12 5-11-12 7-11-12
66 62 59 60 71 61 59 60
163 266 208 179 167 163 163 164
144 150 146 143 142 142 141 147
140 152 145 148 155 176 152 140
111 116 113 111 108 108 108 109
71 83 73 74 63 67 64 68
66 92 72 72 67 73 69 91
52 53 53 52 78
110 74 52
170 195 175 185 175 190 176 169
51 54 50 52 48 52 49 53
118 118 112 111 114 118 113 116
1.9 2.3 2.1 2.0 2.4 3.0 2.3 1.9
2-11-12-15 2-10-11-12 2-5-11-12 2-7-11-12 2-4-11-12
71 76 63 65 65
266 271 266 267 267
153 152 150 156 151
152 167 164 152 189
120 116 116 118 116
93 84 84 90 89
92 92 94
117 100
54 80 75 53
111
197 202 202 195 216
58 54 56 61 59
125 122 121 124 126
2.3 2.8 2.7 2.3 3.4
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Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin % RDA
A Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
100 100
364 394
164 179
192 212
120 139
102 134
126 147
120 121
229 261
72 90
147 155
4.1 4.3
Maximizeda 121 1136 246 249 177 262 199 152 318 92 159 6.0
No Recommendations 44 163 57 58 32 42 28 28 126 16 43 1.5
2-7-10-11-12 2-5-7-11-12 3-7-10-11-12 3-5-7-11-12 2-4-7-11-12 2-10-11-12-15 2-4-11-12-15
79 66 76 63 69 85 75
271 267 213 209 267 271 266
158 157 155 153 158 154 154
168 164 160 157 190 167 189
118 118 114 114 118 120 120
92 92 81 81 97 95
101
119 120 98
100 127 92
100
80 75 79 75
111 80
111
202 202 182 182 216 203 218
61 62 56 58 65 58 63
128 127 122 121 132 129 134
2.8 2.7 2.6 2.5 3.4 2.8 3.4
2-5-7-11-12-13 2-5-7-11-12-14 2-4-7-11-12-13 2-4-7-11-12-14 2-7-10-11-12-13 2-7-10-11-12-15 2-4-7-11-12-15
69 68 72 70 82 84 78
301 286 301 286 305 166 267
157 157 158 158 158 152 161
167 166 193 191 171 155 190
126 122 126 122 126 114 123
117 106 122 111 116 81
112
124 122 131 129 123 92
127
76 76
112 112 80 79
112
202 202 216 216 202 177 218
64 63 67 66 62 57 70
130 129 136 134 131 128 141
2.8 2.7 3.5 3.4 2.9 2.4 3.4
2-5-7-11-12-13-15 2-7-10-11-12-13-15
79 92
301 305
160 162
167 171
132 132
131 131
124 123
76 80
204 203
68 67
138 139
2.8 2.9
a Refers to maximized diet, that is, a diet following the final set of FBRs in which nutrient intake is maximized.
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Appendix 19. Module 3, Stage 1: Formulation of FBRs for Non-Breastfed Children 12–23 Months Old with Incaparina and Fortified Instant Oats – Selection of the Key Messages
Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
100 100
593 349
215 2202
211 206
161 167
151 138
121 104
108 108
175 153
111 115
158 164
5.7 5.7
Maximizeda 124 1002 337 270 252 391 246 115 313 124 197 8.5
No Recommendations 17 6 70 36 42 53 18 3 53 28 39 2.5
1 2 3 4 5 6 7 8 9
10 11 12 13 14
Fruit7 Dairy7 Veg14 Veg21 MPE7 MPE3 Staple21 Incap7 Fort oat7 Beans7 GLV7 Potato4 Veg28 Potato7
17 25 17 18 20 17 37 30 19 20 25 19 24 25
45 9
20 54 7 7 7 7 7 7
57 32
104 51
70 71 72 75 71 70 71
150 76 83 72 70 80 73
36 46 38 40 65 43 36
113 47 37 43 38 44 39
42 42 44 46 49 42 43
114 52 43 44 47 49 51
54 53 56 60 56 53 68 53 67 61 64 69 70 80
19 18 19 23 23 19 18 49 26 64 26 20 32 22
3 20 3 3
58 21 3
32 3 3 3 3 4 4
53 57 54 58 70 56 54 70 68 53 81 53 78 53
28 28 29 30 31 29 28 49 36 33 32 29 32 35
39 41 39 40 50 42 49
116 39 45 40 41 41 50
2.6 2.8 2.6 2.7 3.7 3.0 2.5 2.7 2.6 2.9 2.6 2.6 2.8 2.6
15 16 17 18 19 20
7-8-9-2 7-8-9-5 7-8-9-6 7-8-9-4 7-8-9-10 7-8-9–11
62 57 54 55 57 62
9 7 7
54 7
57
163 163 162 167 175 164
135 154 133 130 126 133
124 132 124 128 125 126
80 88 81 88 93 91
59 64 60 64
104 66
49 87 50 33 33 32
89 101 88 89 85
113
58 61 59 60 64 62
132 142 134 131 136 131
3.4 4.3 3.6 3.3 3.5 3.2
21 22 23
7-8-9-2-10 7-8-9-2-11 7-8-9-5-10
66 70 60
9 60 7
177 165 176
136 142 155
125 126 132
94 92
102
104 67
109
50 49 88
89 117 101
64 62 67
139 134 149
3.8 3.5 4.7
24 25
7-8-9-2-10-11 7-8-9-2-10-5
74 69
60 10
179 178
143 164
127 132
106 204
112 110
50 104
117 105
68 67
140 151
3.9 5.0
26 27 28 29 30
7-8-9-2-10-11-5 7-8-9-2-10-11-6 7-8-9-10-5-13-14 7-8-9-10-4-6-12 7-8-9-10-4-6-14
77 75 74 62 65
60 60
149 80 98
180 180 187 181 181
171 149 166 138 139
134 127 151 135 138
115 109 155 123 137
117 113 126 112 113
104 66 89 52 52
133 120 126 93 93
71 69 74 68 70
152 144 159 144 150
5.1 4.3 5.2 4.2 4.3
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Calcium % RDA
Vitamin % RDA
C Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin % RDA
A Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
100 100
593 349
215 2202
211 206
161 167
151 138
121 104
108 108
175 153
111 115
158 164
5.7 5.7
Maximizeda 124 1002 337 270 252 391 246 115 313 124 197 8.5
No Recommendations 17 6 70 36 42 53 18 3 53 28 39 2.5
31 32 33
7-8-9-2-10-11-5-12 7-8-9-10-4-6-12-2 7-8-9-10-4-6-13-2
82 71 73
104 82
101
181 183 183
174 148 149
144 135 138
148 125 139
121 112 114
105 68 69
133 97 97
73 68 70
160 147 152
5.2 4.5 4.6
a Refers to maximized diet, that is, a diet following the final set of FBRs in which nutrient intake is maximized.
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Appendix 20. Module 3, Stage 1: Formulation of FBRs for Pregnant Women with Incaparina and Fortified Instant Oats and Liver – Selection of the Key Messages
Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
144 139
186 206
126 144
141 164
120 155
137 135
72 96
381 407
287 287
100 115
86 90
13.3 15.6
Maximizeda 179 302 162 178 169 216 105 409 334 136 103 18.2
No Recommendations 71 2 63 37 51 83 9 4 39 44 46 7.9
1 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16 17 18 19 20
Fruit7 Veg27 MPE7 Dairy7 VtC7Frt7 GLV7 Beans7 Egg3 Redmeat1 Chicken2 Incap7 Fort oats7 Chayote3 Orange1 Liver1 Veg21 VtCveg7 Potato7 Orange7 Orange3
71 78 72 79 71 75 75 72 71 71 77 75 72 72 71 73 71 74 76 73
12 57 2 3
12 12 2 2 2 2 2 2
18 17 4
24 13 16
107 47
63 68 63 63 63 64 68 63 63 63 88 70 64 64 64 66 64 63 70 66
37 48 47 45 37 43 38 44 38 39 68 48 39 38 64 42 38 39 40 38
51 57 61 51 51 53 51 51 52 66 77 61 52 51 59 54 52 56 51 51
83 96 83 83 84 90 84 83 83 84 83 94 84 83 86 90 84 94 84 84
9 25 10 9 9
12 27 10 9 9
17 14 18 10 12 12 9
11 16 12
4 5
33 16 4 4 4
14 15 8
15 4 4 4
338 4 4 4 4 4
39 101 47 43 39 59 39 44 39 41 47 58 40 40
148 52 42 39 41 40
44 51 45 44 44 48 49 45 44 44 54 55 45 44 46 46 45 45 44 44
46 49 48 46 46 46 48 46 48 46 64 46 48 46 48 46 46 46 46 46
8.1 9.1
10.4 8.6 8.1 8
7.9 8.5 8.6 9.2 8.2 8.2 8.1 7.9 7.9 8.2 8.0 8.1 8.2 8.0
21 22 23 24 25
2-7-11 2-3-11 2-7-15 2-11-15 7-11-15
90 85 82 84 82
57 57 60 59 5
99 94 75 95 94
79 88 76
106 95
83 93 65 91 85
97 96
100 98 87
52 35 47 37 39
16 45
339 350 349
109 117 210 218 156
68 61 59 63 62
71 71 54 70 70
9.4 11.8 9.0 9.3 8.2
26 27
2-7-11-15 2-3-7-11
90 90
60 57
100 99
106 90
91 93
100 98
56 54
350 45
218 117
70 69
74 74
9.3 11.1
26 27 28 29
2-7-11-14-15* 2-7-11-15*-18 2-6-7-11-15* 2-7-11-15*-19
91 93 90 95
75 74 60
165
101 100 100 108
107 108 106 109
91 96 91 92
100 112 100 102
57 58 56 63
350 350 350 350
218 218 218 220
70 72 70 70
74 74 74 74
9.4 9.5 9.3 9.6
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Calcium % RDA
Vitamin % RDA
C Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin % RDA
A Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
144 139
186 206
126 144
141 164
120 155
137 135
72 96
381 407
287 287
100 115
86 90
13.3 15.6
Maximizeda 179 302 162 178 169 216 105 409 334 136 103 18.2
No Recommendations 71 2 63 37 51 83 9 4 39 44 46 7.9
3031 32 33
2-7-11-12-14-15* 2-7-11-12-15*-18 2-7-11-12-15*-19 2-7-11-15*-18-19
95 97
100 98
75 74
165 179
109 108 116 108
117 119 120 111
101 106 102 97
110 122 112 115
62 63 68 65
350 350 350 350
238 238 240 220
81 83 81 72
75 76 75 74
9.7 9.9
10.0 9.9
34 35
2-7-11-12-15*-18-19 2-7-11-12-14-15*-18
103 98
179 89
116 109
121 119
106 106
124 122
70 64
350 350
240 238
83 83
76 76
10.2 9.9
a Refers to maximized diet, that is, a diet following the final set of FBRs in which nutrient intake is maximized.
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Appendix 21. Module 3, Stage 1: Formulation of FBRs for Lactating Women with Incaparina and Fortified Instant Oats – Selection of the Key Messages
Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
183 192
110 102
154 157
136 138
179 174
153 140
100 101
356 359
202 198
130 133
97 100
19.2 19.1
Maximizeda 221 219 202 178 216 223 132 364 256 162 106 22.3
No Recommendations 103 9 84 40 67 107 16 5 28 64 57 9.7
1 2 3 4 5 6 7 8 9
10 11 12 13
Veg28 Veg21 VitC-veg7 GLV7 Chayote3 VC-frt7 Incap7 MPE7 Liver1 Beans7 Fort oats7 Potato7 Orange3
106 104 103 108 103 108 113 103 103 105 111 108 107
36 21 13 12 15 16 9 9
11 9 9
24 56
88 86 84 84 84 86
116 84 85 90 96 85 89
44 41 40 46 41 40 69 51 64 41 50 42 41
71 69 67 68 68 67 98 67 76 68 78 74 68
113 110 107 113 107 107 108 107 109 108 121 121 107
24 18 16 22 25 16 27 18 20 37 22 19 21
5 5 5 5 5 5
16 24
315 5 5 5 5
39 30 28 46 28 28 35 34
104 28 44 28 29
66 65 67 68 64 67 78 64 66 67 79 66 65
58 57 59 57 59 59 76 58 60 59 58 60 58
10.2 9.9 9.8 9.7 9.8 9.8
10.1 11 10 10
10.1 9.9 9.8
14 15 16 17
1-7-9 1-7-10 1-9-10 7-9-10
115 117 108 114
38 36 38 11
122 126 95
123
97 74 69 94
110 102 80
106
117 116 117 112
40 57 50 53
326 16
315 326
122 46
115 111
82 83 71 83
79 78 62 80
10.8 10.9 10.8 10.7
18 1-7-9-10 117 38 127 98 110 118 61 326 122 85 80 11.2
19 20 21 22 23 24 25
1-3-7-9-10 1-4-7-9-10 1-5-7-9-10 1-6-7-9-10 1-9-10-11 1-7-9-10-12 1-7-9-10-13
117 119 117 120 124 122 121
38 38 41 44 38 53 84
127 127 127 128 138 128 132
98 102 98 98
110 101 100
110 110 110 110 123 117 111
118 122 118 118 132 132 118
61 61 68 62 68 64 66
326 326 326 326 326 327 327
122 131 122 122 138 122 122
85 88 85 88
100 87 85
80 80 82 81 82 83 81
11.2 11.2 11.2 11.3 11.6 11.5 11.4
26 27 28
1-5-6 -7-9-10 1-7-9-10-11-12 1-7-9-10-11-13
120 129 128
47 53 84
128 138 143
98 112 111
110 130 123
118 147 133
68 71 73
326 327 327
122 138 139
88 102 101
83 84 83
11.3 11.9 11.8
29 30
1-7-9-10-11-12-13 2-7-9-10-11-12-13
133 130
99 84
143 141
113 110
130 128
147 144
76 69
327 327
139 130
103 102
85 85
12.1 11.7
a Refers to maximized diet, that is, a diet following the final set of FBRs in which nutrient intake is maximized.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Appendix 22. Module 3, Stages 2–3: Formulation of FBRs for Breastfed Children 6–8 Months Old with Incaparina and Fortified Instant Oatsa
# Nutb
< 70% RDA Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
89 94
100 100
136 124
141 139
108 117
139 155
182 173
109 106
117 123
74 78
63 64
1.7 1.8
Maximizedc 97 138 152 166 135 245 213 146 144 80 66 3.0
No Recommendations 10 48 50 49 58 31 36 42 51 75 14 22 0.8
1 2 3 4 5 6 7
Veg28 MPE7 Beans7 Staple21 Incaparina7 Fort oats7 Potato7
10 9 9
10 6 9 9
51 51 50 56 54 54 52
64 50 50 50 50 50 59
55 50 56 53 90 69 50
64 83 58 58 94 77 61
36 34 33 36 73 53 43
54 46 45 52 36 67 75
67 54 79 42 66 65 49
52 107 51 51 71 51 52
ok 2
ok ok ok ok ok ok
17 16 17 15 26 34 16
24 26 24 26 44 24 25
1.0 1.6 0.8 0.8 0.9 0.8 0.9
8 5-6 5 59 50 ok ok ok 67 89 ok ok 48 46 0.9
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1-2 1-3 1-4 1-7 1-8 2-3 2-4 2-7 2-8 3-4 3-7 3-8 4-7 4-8 7-8
7 9 9 7 4 7 8 7 4 9 8 4 9 4 4
53 52 60 55 62 52 59 55 62 58 54 61 61 68 63
64 64 64 74 64 50 50 59 50 50 59 50 59 50 59
56 62 58 67 ok 58 54 51 ok 60 62 ok 53 ok ok
89 65 64 67 ok 84 83 87 ok 58 62 ok 61 ok ok
39 39 42 49 ok 36 39 46 ok 39 46 ok 49 ok ok
65 63 71 ok 85 56 64 ok 78 63 ok 77 ok 85 ok
78 ok 67 73 ok ok 54 61 ok ok ok ok 49 ok ok
ok 52 52 53 ok ok ok ok ok 51 52 ok 52 ok ok
ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok
19 20 19 19 50 19 18 18 50 19 19 50 17 50 49
28 26 28 27 48 27 29 28 50 28 26 50 28 50 49
1.7 1.0 1.0 1.1 1.1 1.6 1.6 1.7 1.7 0.8 0.9 0.9 0.9 0.9 1.0
24 25 26 27 28 29 30 31 32 33
1-2-3 1-2-4 1-2-7 1-2-8 1-3-4 1-3-7 1-3-8 1-4-7 1-4-8 1-7-8
6 6 5 4 8 7 4 7 3 3
55 63 58 66 61 57 64 64 72 66
64 64 ok 64 64 ok 64 ok 64 ok
63 59 56 ok 65 62 ok 58 ok ok
ok ok ok ok 65 68 ok 67 ok ok
42 45 52 ok 45 52 ok 55 ok ok
75 ok ok ok ok ok ok ok ok ok
ok ok ok ok ok ok ok ok ok ok
ok ok ok ok 52 53 ok 53 ok ok
ok ok ok ok ok ok ok ok ok ok
23 22 21 54 22 22 54 21 54 53
30 32 30 52 30 29 50 31 52 51
1.7 1.7 1.8 1.9 1.0 1.1 1.1 1.1 1.1 1.2
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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<
# Nutb 70% RDA
Calcium % RDA
Vitamin % RDA
C Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin % RDA
A Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
89 94
100 100
136 124
141 139
108 117
139 155
182 173
109 106
117 123
74 78
63 64
1.7 1.8
Maximizedc 97 138 152 166 135 245 213 146 144 80 66 3.0
No Recommendations 10 48 50 49 58 31 36 42 51 75 14 22 0.8
34 2-3-4 6 61 50 61 ok 42 75 ok ok ok 22 31 1.6 35 2-3-7 6 56 59 58 ok 49 ok ok ok ok 21 30 1.7 36 2-3-8 4 63 50 ok ok ok ok ok ok ok 52 50 1.7 37 2-4-7 7 63 59 54 ok 52 ok 61 ok ok 21 32 1.7 38 2-4-8 3 72 50 ok ok ok ok ok ok ok 54 54 1.7 39 2-7-8 4 66 59 ok ok ok ok ok ok ok 53 52 1.8 40 3-4-7 8 62 59 60 62 51 ok ok 52 ok 21 30 0.9 41 3-4-8 3 70 50 ok ok ok ok ok ok ok 54 52 0.9 42 3-7-8 4 65 59 ok ok ok ok ok ok ok 53 51 1.0 43 4-7-8 3 72 59 ok ok ok ok ok ok ok 53 52 1.0
44 1-2-3-4 6 64 64 66 ok 48 ok ok ok ok 26 34 1.8 45 1-2-3-7 5 59 ok 63 ok 54 ok ok ok ok 25 32 1.8 46 1-2-3-8 4 67 64 ok ok ok ok ok ok ok 58 54 1.9 47 1-2-4-7 5 67 ok 60 ok 58 ok ok ok ok 25 34 1.9 48 1-2-4-8 3 ok 64 ok ok ok ok ok ok ok 58 56 1.9 49 1-2-7-8 2 70 ok ok ok ok ok ok ok ok 57 55 2.0 50 1-3-4-7 7 65 ok 66 68 57 ok ok 53 ok 25 32 1.1 51 1-3-4-8 3 ok 64 ok ok ok ok ok ok ok 54 52 1.1 52 1-3-7-8 3 68 ok ok ok ok ok ok ok ok 57 53 1.2 53 1-4-7-8 2 ok ok ok ok ok ok ok ok ok 57 55 1.2 54 2-3-4-7 6 65 59 61 ok 54 ok ok ok ok 25 34 1.7 55 2-3-4-8 3 ok 50 ok ok ok ok ok ok ok 58 56 1.7 56 2-3-7-8 4 68 59 ok ok ok ok ok ok ok 57 54 1.8 57 2-4-7-8 3 ok 59 ok ok ok ok ok ok ok 57 56 1.8 58 3-4-7-8 3 ok 59 ok ok ok ok ok ok ok 57 54 1.0
59 1-2-3-4-7 5 68 ok 67 ok 60 ok ok ok ok 29 36 1.9 60 1-2-3-4-8 3 ok 64 ok ok ok ok ok ok ok 62 58 1.9 61 1-2-3-7-8 2 ok ok ok ok ok ok ok ok ok 61 56 2.0 62 1-2-4-7-8 2 ok ok ok ok ok ok ok ok ok 61 59 2.0 63 1-3-4-7-8 2 ok ok ok ok ok ok ok ok ok 61 57 1.2 64 2-3-4-7-8 2 ok 59 ok ok ok ok ok ok ok 61 59 1.8
65 1-2-3-4-7-8 2 82 75 133 152 126 168 171 129 126 67 61 2.0 a “ok” means that a subset of the set of FBRs tested ensured that ≥ 70% of the RDA was achieved. b number of nutrients < 70% of their RDAs in worst-case scenarios for this FBR. c Refers to maximized diet, that is, a diet following the final set of FBRs in which nutrient intake is maximized.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Appendix 23. Module 3, Stages 2–3: Formulation of FBRs for Breastfed Children 9–11 Months Old with Incaparina and Fortified Instant Oatsa
# Nutb
< 70% RDA Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
112 114
114 117
158 165
176 176
138 130
189 185
210 210
140 138
152 146
100 100
76 77
2.7 2.6
Maximizedc 125 203 205 207 203 374 271 146 195 136 78 3.6
No Recommendations 10 47 49 57 63 41 54 45 51 81 16 23 1.1
1 2 3 4 5 6 7
Veg28 MPE7 Beans7 Staple21 Incaparina7 Fort oats7 Potato7
6 8 9
10 6 7 9
59 50 51 60 54 55 54
89 49 49 49 49 49 59
69 58 64 61
103 82 58
84 86 64 63
103 87 66
50 40 40 42 84 67 51
95 57 61 68 54 94 91
91 52 83 45 70 73 51
52 101 51 51 73 51 52
ok 2
ok ok ok ok ok ok
39 19 22 20 31 44 23
27 26 26 28 47 26 30
1.4 1.7 1.1 1.1 1.2 1.2 1.2
8 5-6 4 62 49 ok ok ok ok ok 73 ok 58 50 1.3
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1-2 1-3 1-4 1-7 1-8 2-3 2-4 2-7 2-8 3-4 3-7 3-8 4-7 4-8 7-8
4 5 4 5 1 7 7 7 4 8 8 4 9 3 4
61 62 72 65 74 53 62 56 64 63 57 65 65 75 68
ok ok ok ok ok 49 49 59 49 49 59 49 59 49 59
70 76 74 70 ok 65 62 59 ok 68 65 ok 62 ok ok
ok ok ok ok ok ok ok ok ok 64 67 ok 66 ok ok
50 51 54 61 ok 40 42 51 ok 44 52 ok 54 ok ok
ok ok ok ok ok 67 75 ok ok 79 ok ok ok ok ok
ok ok ok ok ok ok 52 59 ok ok ok ok 51 ok ok
102 52 53 53 74 ok ok ok ok 52 52 73 52 73 74
ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok
42 46 43 44 81 25 23 24 61 26 26 64 24 62 61
31 31 33 33 55 29 32 32 54 32 32 54 33 56 55
2.0 1.4 1.4 1.5 1.7 1.7 1.7 1.8 1.9 1.1 1.2 1.3 1.2 1.3 1.4
24 25 26 27 28 29 30 31 32 33
1-2-3 1-2-4 1-2-7 1-2-8 1-3-4 1-3-7 1-3-8 1-4-7 1-4-8 1-7-8
4 3 4 1 4 5 1 4 1 1
65 ok 67 ok ok 68 ok ok ok ok
ok ok ok ok ok ok ok ok ok ok
ok ok ok ok ok ok ok ok ok ok
ok ok ok ok ok ok ok ok ok ok
51 54 61 ok 57 63 ok 66 ok ok
ok ok ok ok ok ok ok ok ok ok
ok ok ok ok ok ok ok ok ok ok
ok ok ok ok 53 54 ok 54 ok ok
ok ok ok ok ok ok ok ok ok ok
48 46 45 ok 49 48 ok 46 ok ok
34 37 36 59 37 36 59 37 61 59
2.0 2.0 2.1 2.2 1.4 1.5 1.7 1.5 1.7 1.7
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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<
# Nutb 70% RDA
Calcium % RDA
Vitamin % RDA
C Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin % RDA
A Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
112 114
114 117
158 165
176 176
138 130
189 185
210 210
140 138
152 146
100 100
76 77
2.7 2.6
Maximizedc 125 203 205 207 203 374 271 146 195 136 78 3.6
No Recommendations 10 47 49 57 63 41 54 45 51 81 16 23 1.1
34 2-3-4 6 66 49 69 ok 44 ok ok ok ok 29 36 1.7 35 2-3-7 6 58 59 66 ok 52 ok ok ok ok 28 34 1.8 36 2-3-8 4 68 49 ok ok ok 107 ok ok ok 67 58 1.9 37 2-4-7 7 67 59 62 ok 54 ok 59 ok ok 25 36 1.8 38 2-4-8 3 ok 49 ok ok ok ok ok ok ok 65 60 1.9 39 2-7-8 4 69 59 ok ok ok ok ok ok ok 63 58 2.0 40 3-4-7 9 68 59 69 67 57 ok 89 52 ok 28 36 1.2 41 3-4-8 3 ok 49 ok ok ok ok ok ok ok 68 60 1.3 42 3-7-8 3 70 59 ok ok ok ok ok ok ok 66 58 1.4 43 4-7-8 3 ok 59 ok ok ok ok ok ok ok 64 60 1.4
44 1-2-3-4 3 ok ok ok ok 57 ok ok ok ok 52 41 2.0 45 1-2-3-7 3 70 ok ok ok 63 ok ok ok ok 51 38 2.1 46 1-2-3-8 1 ok ok ok ok ok ok ok ok ok ok 63 2.2 47 1-2-4-7 2 ok ok ok ok 66 ok ok ok ok 49 40 2.1 48 1-2-4-8 1 ok ok ok ok ok ok ok ok ok ok 65 2.2 49 1-2-7-8 1 ok ok ok ok ok ok ok ok ok ok 63 2.3 50 1-3-4-7 3 ok ok ok ok 70 ok ok 54 ok 52 40 1.5 51 1-3-4-8 1 ok ok ok ok ok ok ok ok ok ok 65 1.7 52 1-3-7-8 1 ok ok ok ok ok ok ok ok ok 90 63 1.7 53 1-4-7-8 1 ok ok ok ok ok ok ok 75 ok 88 64 1.7 54 2-3-4-7 4 70 59 70 ok 57 ok ok ok ok 32 39 1.8 55 2-3-4-8 2 ok 49 ok ok ok ok ok ok ok 72 64 1.9 56 2-3-7-8 2 ok 59 ok ok ok ok ok ok ok 70 61 2.0 57 2-4-7-8 3 ok 59 ok ok ok ok ok ok ok 68 63 2.0 58 3-4-7-8 2 ok 59 ok ok ok ok ok ok ok 71 63 1.4
59 1-2-3-4-7 2 ok ok ok ok ok ok ok ok ok 56 43 2.2 60 1-2-3-4-8 1 ok ok ok ok ok ok ok ok ok ok 69 2.3 61 1-2-3-7-8 1 ok ok ok ok ok ok ok ok ok ok 66 2.3 62 1-2-4-7-8 1 ok ok ok ok ok ok ok ok ok ok 68 2.3 63 1-3-4-7-8 1 ok ok ok ok ok ok ok ok ok ok 68 1.8 64 2-3-4-7-8 1 ok 59 ok ok ok ok ok ok ok ok 67 2.0
65 1-2-3-4-7-8 0 97 100 159 180 147 219 206 129 137 100 72 2.4 a “ok” means that a subset of the set of FBRs tested ensured that ≥ 70% of the RDA was achieved. b number of nutrients < 70% of their RDAs in worst-case scenarios for this FBR. c Refers to maximized diet, that is, a diet following the final set of FBRs in which nutrient intake is maximized.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Appendix 24. Module 3, Stages 2–3: Formulation of FBRs for Breastfed Children 12–23 Months Old with Incaparina and Fortified Instant Oatsa
# Nutb
< 70% RDA Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
100 100
364 394
164 179
192 212
120 139
102 134
126 147
120 121
229 261
72 90
147 155
4.1 4.3
Maximizedc 121 1136 246 249 177 262 199 152 318 92 159 6.0
Number Recommended 9 44 163 57 58 32 42 28 28 126 16 43 1.5
1 2 3 4 5 6 7
Veg28 MPE7 Beans7 Staple21 Incaparina7 Fort oats7 Potato7
9 8 9 9 6 8 9
47 46 46 51 53 48 46
ok2 ok ok ok ok ok ok
66 58 63 59
124 73 58
70 94 58 58
122 76 50
40 32 32 34 91 48 39
62 46 47 50 42 63 64
53 35 52 28 53 41 31
29 86 28 28 52 28 29
ok ok ok ok ok ok ok
21 17 19 17 32 30 17
50 50 48 48
107 46 46
1.9 2.6 1.5 1.5 1.7 1.7 1.6
8 5-6 5 58 ok ok ok 108 63 66 52 ok 48 ok 1.9
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1-2 1-3 1-4 1-7 1-8 2-3 2-4 2-7 2-8 3-4 3-7 3-8 4-7 4-8 7-8
7 7 7 7 3 7 7 6 4 9 8 4 8 4 4
50 50 55 50 62 48 54 49 61 54 48 60 54 66 61
ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok
67 72 68 66 ok 64 60 58 ok 65 63 ok 59 ok ok
107 71 70 73 ok 95 94 96 ok 58 60 ok 60 ok ok
40 40 42 47 ok 32 34 39 ok 34 39 ok 41 ok ok
68 69 72 85 83 54 57 70 67 58 71 68 74 71 85
61 78 53 56 92 60 35 38 73 52 55 91 31 66 69
ok 29 29 30 53 ok ok ok ok 28 29 52 29 52 53
ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok
24 26 23 22 54 22 20 19 52 21 21 53 18 51 49
58 56 55 53 ok 56 56 54 ok 54 51 ok 51 ok ok
3.0 1.9 1.9 2.0 2.3 2,6 2,6 2.7 3,0 1.5 1.6 1.9 1.6 1.9 2.0
24 25 26 27 28 29 30 31 32
1-2-3 1-2-4 1-2-7 1-2-8 1-3-4 1-3-7 1-3-8 1-4-7 1-4-8
4 6 6 2 5 5 3 7 2
52 58 53 65 58 52 65 58 71
ok ok ok ok ok ok ok ok ok
73 69 67 ok 74 72 ok 68 ok
ok ok ok ok ok ok ok ok ok
40 42 47 ok 43 48 ok 49 ok
76 ok ok ok ok ok ok ok ok
ok 61 64 ok ok ok ok 56 ok
ok ok ok ok 29 30 53 30 54
ok ok ok ok ok ok ok ok ok
30 27 26 59 29 27 61 25 58
64 64 61 ok 61 59 ok 59 ok
3.0 3.0 3.1 3.4 1.9 2.0 2.3 2.0 2.3
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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# Nutb
< 70% RDA Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
100 100
364 394
164 179
192 212
120 139
102 134
126 147
120 121
229 261
72 90
147 155
4.1 4.3
Maximizedc 121 1136 246 249 177 262 199 152 318 92 159 6.0
Number Recommended 9 44 163 57 58 32 42 28 28 126 16 43 1.5
33 1-7-8 3 65 ok ok ok ok ok ok 54 ok 56 ok 2.4 34 2-3-4 7 57 ok 67 ok 34 66 60 ok ok 26 62 2.6 35 2-3-7 6 52 ok 64 ok 39 ok 64 ok ok 24 60 2.7 36 2-3-8 2 64 ok ok ok ok 91 ok ok ok 53 ok 3.1 37 2-4-7 6 57 ok 60 ok 41 ok 38 ok ok 22 59 2.7 38 2-4-8 1 70 ok ok ok ok 78 73 ok ok 55 ok 3.0 39 2-7-8 3 64 ok ok ok ok ok 77 ok ok 53 ok 3.1 40 3-4-7 8 57 ok 65 60 42 ok 55 29 ok 23 57 1.6 41 3-4-8 2 70 ok ok ok ok 79 ok 52 ok 57 ok 1.9 42 3-7-8 3 63 ok ok ok ok ok ok 53 ok 55 ok 2.0 43 4-7-8 4 60 ok ok ok ok 96 69 53 ok 53 ok 2.0
44 1-2-3-4 3 62 ok ok ok 43 ok ok ok ok 33 70 3.0 45 1-2-3-7 4 56 ok ok ok 48 ok ok ok ok 32 67 3.1 46 1-2-3-8 2 66 ok ok ok ok ok ok ok ok 60 ok 3,4 47 1-2-4-7 6 61 ok 69 ok 49 ok 64 ok ok 29 67 3.1 48 1-2-4-8 1 ok ok ok ok ok ok ok ok ok 63 ok 3.4 49 1-2-7-8 2 68 ok ok ok ok ok ok ok ok 61 ok 3.5 50 1-3-4-7 5 61 ok ok ok 52 ok ok 30 ok 31 65 2,0 51 1-3-4-8 2 ok ok ok ok ok ok ok 54 ok 65 ok 2,3 52 1-3-7-8 3 68 ok ok ok ok ok ok 54 ok 62 ok 2.4 53 1-4-7-8 3 74 ok ok ok ok ok ok 54 ok 60 ok 2.4 54 2-3-4-7 6 60 ok 67 ok 42 ok 64 ok ok 28 65 2.7 55 2-3-4-8 2 74 ok ok ok ok ok ok ok ok 62 ok 3.0 56 2-3-7-8 2 67 ok ok ok ok ok ok ok ok 60 ok 3.1 57 2-4-7-8 1 ok ok ok ok ok ok ok ok ok 58 ok 3.1 58 3-4-7-8 2 ok ok ok ok ok ok ok 53 ok 59 ok 2.0
59 1-2-3-4-7 3 65 ok ok ok 52 ok ok ok ok 35 ok 3.1 60 1-2-3-4-8 0 ok ok ok ok ok ok ok ok ok 70 ok 3.4 61 1-2-3-7-8 1 72 ok ok ok ok ok ok ok ok 67 ok 3.5 62 1-2-4-7-8 1 ok ok ok ok ok ok ok ok ok 65 ok 3.5 63 1-3-4-7-8 2 ok ok ok ok ok ok ok 54 ok 67 ok 2.4 64 2-3-4-7-8 1 ok ok ok ok ok ok ok ok ok 64 ok 3.1
65 1-2-3-4-7-8 0 82 301 162 193 132 138 131 112 218 72 144 3.5 a “ok” means that a subset of the set of FBRs tested ensured that ≥ 70% of the RDA was achieved. b number of nutrients < 70% of their RDAs in worst-case scenarios for this FBR. c Refers to maximized diet, that is, a diet following the final set of FBRs in which nutrient intake is maximized.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Appendix 25. Module 3, Stages 2–3: Formulation of FBRs for Non-Breastfed Children 12–23 Months Old with Incaparina and Fortified Instant Oatsa
# Nutb
< 70% RDA Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
100 100
593 349
215 2202
211 206
161 167
151 138
121 104
108 108
175 153
111 115
158 164
5.7 5.7
Maximizedc 124 1002 337 270 252 391 246 115 313 124 197 8.5
Number Recommended 10 17 6 70 36 42 53 18 3 53 28 39 2.5
1 2 3 4 5 6 7
Veg28 MPE7 Beans7 Staple21 Incaparina7 Fort oats7 Potato7
7 10 10 10 6
10 9
24 20 20 37 30 19 25
104 7 7 7 7 7
51
ok ok ok ok ok ok ok
44 65 37 36
113 47 39
49 49 43 43
113 52 51
70 56 51 68 53 67 80
32 23 64 18 49 26 22
4 58 3 3
32 3 4
78 69 53 54 70 68 53
32 31 33 28 49 36 35
41 50 45 49
116 39 50
2.8 3.7 2.9 2.5 2.7 2.6 2.6
8 5-6 6 33 7 ok ok ok 67 59 32 ok 57 ok 3.1
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1-2 1-3 1-4 1-7 1-8 2-3 2-4 2-7 2-8 3-4 3-7 3-8 4-7 4-8 7-8
6 6 7 7 3
10 8 9 5 9 9 4 9 5 5
28 28 45 32 41 23 40 27 36 41 28 36 43 54 40
ok ok ok ok ok 7 7
51 7 7
51 7
51 7
51
ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok
73 45 44 47 ok 66 65 65 ok 37 40 ok 39 ok ok
57 51 50 58 ok 51 50 58 ok 44 52 ok 52 ok ok
ok ok ok ok ok 67 77 ok 68 82 ok ok ok ok ok
37 77 32 35 72 69 23 27 64 64 68
104 22 59 62
58 4 4 4
33 58 58 58 87 4 4
33 4
32 33
ok ok ok ok ok 69 70 69 ok 54 53 ok 54 ok ok
35 38 32 39 62 36 31 37 60 34 40 63 35 58 63
52 47 52 52 ok 56 60 59 ok 55 55 ok 60 ok ok
4.0 3.3 2.8 3.0 3.4 4.2 3.7 3.8 4.3 2.9 3.0 3.5 2.6 3.1 3.2
24 25 26 27 28 29 30 31 32
1-2-3 1-2-4 1-2-7 1-2-8 1-3-4 1-3-7 1-3-8 1-4-7 1-4-8
5 6 6 2 6 6 3 7 3
31 48 34 44 49 35 44 51 62
ok ok ok ok ok ok ok ok ok
ok ok ok ok ok ok ok ok ok
ok ok ok ok 45 49 ok 47 ok
58 58 66 ok 52 60 ok 59 ok
ok ok ok ok ok ok ok ok ok
ok 37 42 ok ok ok ok 35 ok
59 59 59 ok 4 5
33 5
33
ok ok ok ok ok ok ok ok ok
41 36 40 65 38 44 68 39 62
59 63 62 ok 58 57 ok 62 ok
4.5 4.0 4.2 4.6 3.3 3.4 3.9 3.0 3.4
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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# Nutb
< 70% RDA Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
100 100
593 349
215 2202
211 206
161 167
151 138
121 104
108 108
175 153
111 115
158 164
5.7 5.7
Maximizedc 124 1002 337 270 252 391 246 115 313 124 197 8.5
Number Recommended 10 17 6 70 36 42 53 18 3 53 28 39 2.5
33 1-7-8 3 48 ok ok ok ok ok ok 34 ok 67 ok 3.6 34 2-3-4 8 44 7 ok 66 52 ok 69 58 ok 37 66 4.1 35 2-3-7 7 30 51 ok 70 60 98 74 59 69 41 65 4.2 36 2-3-8 3 39 7 ok ok ok ok ok ok ok 66 ok 4.7 37 2-4-7 7 46 51 ok 68 59 ok 27 59 ok 37 70 3.8 38 2-4-8 4 57 7 ok ok ok ok 64 ok ok 61 ok 4.3 39 2-7-8 4 43 51 ok ok ok ok 67 87 ok 64 ok 4.4 40 3-4-7 9 46 51 ok 40 54 ok 68 4 54 40 65 3.0 41 3-4-8 4 55 7 ok ok ok ok ok 32 ok 60 ok 3.3 42 3-7-8 4 43 51 ok ok ok ok ok 33 ok 67 ok 3.6 43 4-7-8 5 59 51 ok ok ok ok 62 33 ok 63 ok 3.2
44 1-2-3-4 5 52 ok ok ok 60 ok ok 59 ok 42 69 4.5 45 1-2-3-7 5 37 ok ok ok 67 ok ok 60 ok 45 68 4.6 46 1-2-3-8 1 48 ok ok ok ok ok ok ok ok 71 ok 5.0 47 1-2-4-7 5 54 ok ok ok 67 ok 41 60 ok 40 72 4.2 48 1-2-4-8 2 65 ok ok ok ok ok ok ok ok 66 ok 4.6 49 1-2-7-8 4 43 51 ok ok ok ok 67 ok ok 64 ok 4.4 50 1-3-4-7 6 54 ok ok 49 62 ok ok 5 ok 44 67 3.4 51 1-3-4-8 3 65 ok ok ok ok ok ok 34 ok 68 ok 3.9 52 1-3-7-8 2 51 ok ok ok ok ok ok 34 ok 71 ok 4.0 53 1-4-7-8 3 67 ok ok ok ok ok ok 34 ok 67 ok 3.6 54 2-3-4-7 5 49 51 ok ok 61 ok ok 59 ok 41 ok 4.2 55 2-3-4-8 3 60 7 ok ok ok ok ok ok ok 67 ok 4.7 56 2-3-7-8 3 45 51 ok ok ok ok ok ok ok 69 ok 4.8 57 2-4-7-8 3 62 51 ok ok ok ok 67 ok ok 64 ok 4.4 58 3-4-7-8 4 62 51 ok ok ok ok ok 34 ok 67 ok 3.6
59 1-2-3-4-7 3 57 ok ok ok 70 ok ok 60 ok 45 ok 4.6 60 1-2-3-4-8 1 69 ok ok ok ok ok ok ok ok ok ok 5.0 61 1-2-3-7-8 1 53 ok ok ok ok ok ok ok ok ok ok 5.2 62 1-2-4-7-8 1 70 ok ok ok ok ok ok ok ok 68 ok 4.7 63 1-3-4-7-8 1 70 ok ok ok ok ok ok 34 ok ok ok 4.0 64 2-3-4-7-8 3 65 51 ok ok ok ok ok ok ok 69 ok 4.8
65 1-2-3-4-7-8 0 74 149 187 166 151 155 126 89 126 74 159 5.2 a “ok” means that a subset of the set of FBRs tested ensured that ≥ 70% of the RDA was achieved. b number of nutrients < 70% of their RDAs in worst-case scenarios for this FBR. c Refers to maximized diet, that is, a diet following the final set of FBRs in which nutrient intake is maximized.
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Appendix 26. Module 3, Stages 2–3: Formulation of FBRs for Pregnant Women with Incaparina and Fortified Instant Oats and Livera
# Nutb
< 70% RDA Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
144 139
186 206
126 144
141 164
120 155
137 135
72 96
381 407
287 287
100 115
86 90
13.3 15.6
Maximizedc 179 302 162 178 169 216 105 409 334 136 103 18.2
Number Recommended 9 71 2 63 37 51 83 9 4 39 44 46 7.9
1 2 3 4 5 6 7
Veg27 Liver1 Beans7 Orange7 Incaparina7 Fort oats7 Potato7
8 7 9 7 7 8 9
ok2 ok ok ok ok ok ok
57 4 2
107 2 2
16
68 64 68 70 88 70 63
48 64 38 40 68 48 39
57 59 51 51 77 61 56
ok ok ok ok ok ok ok
25 12 27 16 17 14 10
5 338
4 4
15 4 4
101 148 39 41 47 60 39
51 46 49 44 54 55 45
49 48 48 46 64 46 46
9.0 7.9 7.9 8.2 8.2 8.1 8.
8 5-6 6 ok 2 ok 79 ok ok 22 15 67 64 65 8.6
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1-2 1-3 1-4 1-7 1-8 2-3 2-4 2-7 2-8 3-4 3-7 3-8 4-7 4-8 7-8
5 8 6 7 4 7 5 7 4 7 9 5 7 5 6
ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok
59 57 ok 71 57 5
ok 18 4
ok 16 2
ok ok 16
70 74 ok 68 ok 68 ok 64 ok ok 68 ok ok ok ok
75 49 51 50 ok 65 67 66 ok 41 40 ok 42 ok ok
65 57 58 64 ok 59 59 63 ok 52 56 ok 56 ok ok
ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok
28 44 32 27 39 30 19 14 26 34 29 41 17 29 24
ok 5 5 5
16 ok ok ok ok 4 4
15 4
15 15
ok ok ok ok ok ok ok ok ok 41 39 67 41 69 67
53 57 51 51 72 52 46 47 67 49 51 71 45 64 65
52 52 49 50 69 51 48 49 66 48 49 68 46 65 66
9.0 9.0 9.4 9.2 9.7 7.9 8.2 8.1 8.6 8.2 8.1 8.6 8.4 8.9 8.8
24 25 26 27 28 29 30 31 32
1-2-3 1-2-4 1-2-7 1-2-8 1-3-4 1-3-7 1-3-8 1-4-7 1-4-8
5 4 5 2 6 6 3 6 3
ok ok ok ok ok ok ok ok ok
60 ok 61 59 ok 71 57 ok ok
ok ok ok ok ok 74 ok ok ok
ok ok ok ok 51 51 ok 53 ok
65 66 66 ok 62 62 ok 62 ok
ok ok ok ok ok ok ok ok ok
47 35 28 42 46 46 58 34 46
ok ok ok ok 5 5
16 5
16
ok ok ok ok ok ok ok ok ok
59 53 53 ok 58 58 ok 51 ok
54 52 52 72 53 53 72 50 69
9.0 9.4 9.1 9.7 9.2 9.2 9.7 9.6
10.0
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# Nutb
< 70% RDA Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
144 139
186 206
126 144
141 164
120 155
137 135
72 96
381 407
287 287
100 115
86 90
13.3 15.6
Maximizedc 179 302 162 178 169 216 105 409 334 136 103 18.2
Number Recommended 9 71 2 63 37 51 83 9 4 39 44 46 7.9
33 1-7-8 2 ok 71 ok ok ok ok 41 16 ok ok 70 9.9 34 2-3-4 5 ok ok ok 68 60 ok 38 ok ok 52 51 8.2 35 2-3-7 7 ok 19 68 67 64 ok 32 ok ok 53 52 8.1 36 2-3-8 4 ok 5 ok ok ok ok 44 ok ok 74 71 8.6 37 2-4-7 5 ok ok ok 69 64 ok 21 ok ok 47 49 8.4 38 2-4-8 3 ok ok ok ok ok ok 33 ok ok 67 68 8.9 39 2-7-8 4 ok 18 ok ok ok ok 28 ok ok 68 69 8.8 40 3-4-7 7 ok ok ok 42 56 ok 36 5 41 51 49 8.4 41 3-4-8 4 ok ok ok ok ok ok 48 15 69 ok 68 8.9 42 3-7-8 5 ok 16 ok ok ok ok 43 15 67 ok 69 8.9 43 4-7-8 5 ok ok ok ok ok ok 31 16 69 65 66 9.1
44 1-2-3-4 4 ok ok ok ok 66 ok 54 ok ok 59 54 9.4 45 1-2-3-7 3 ok ok ok ok 70 ok 49 ok ok 61 56 9.2 46 1-2-3-8 2 ok 60 ok ok ok ok 61 ok ok ok ok 9.7 47 1-2-4-7 2 ok ok ok ok 70 ok 37 ok ok 53 52 9.6 48 1-2-4-8 1 ok ok ok ok ok ok 49 ok ok ok ok 10.0 49 1-2-7-8 1 ok ok ok ok ok ok 44 ok ok ok ok 9.9 50 1-3-4-7 6 ok ok ok 54 63 ok 53 6 ok 58 53 9.6 51 1-3-4-8 2 ok ok ok ok ok ok 65 16 ok ok ok 10.0 52 1-3-7-8 2 ok ok ok ok ok ok 60 16 ok ok ok 9.9 53 1-4-7-8 2 ok ok ok ok ok ok 48 16 ok ok ok 10.2 54 2-3-4-7 5 ok ok ok 70 64 ok 40 ok ok 53 52 8.4 55 2-3-4-8 2 ok ok ok ok ok ok 52 ok ok ok 71 8.9 56 2-3-7-8 3 ok 19 ok ok ok ok 46 ok ok ok 72 8.8 57 2-4-7-8 3 ok ok ok ok ok ok 35 ok ok 68 69 9.1 58 3-4-7-8 4 ok ok ok ok ok ok 50 16 69 ok 69 9.1
59 1-2-3-4-7 3 ok ok ok ok ok ok 56 ok ok 61 56 9.6 60 1-2-3-4-8 1 ok ok ok ok ok ok 68 ok ok ok ok 10.0 61 1-2-3-7-8 1 ok ok ok ok ok ok 63 ok ok ok ok 9.9 62 1-2-4-7-8 1 ok ok ok ok ok ok 51 ok ok ok ok 10.2 63 1-3-4-7-8 2 ok ok ok ok ok ok 67 16 ok ok ok 10.2 64 2-3-4-7-8 2 ok ok ok ok ok ok 54 ok ok ok 72 9.1
65 1-2-3-4-7-8 0 103 179 116 121 106 124 70 350 240 83 76 10.2 a “ok” means that a subset of the set of FBRs tested ensured that ≥ 70% of the RDA was achieved. b number of nutrients < 70% of their RDAs in worst-case scenarios for this FBR. c Refers to maximized diet, that is, a diet following the final set of FBRs in which nutrient intake is maximized.
119
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Appendix 27. Module 3, Stages 2–3: Formulation of FBRs for Lactating Women with Incaparina and Fortified Instant Oats and Livera
# Nutb
<70% RDA Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
183 192
110 102
154 157
136 138
179 174
153 140
100 101
356 359
202 198
130 133
97 100
19.2 19.1
Maximizedc 221 219 202 178 216 223 132 364 256 162 106 22.3
Number Recommended 8 103 9 84 40 67 107 16 5 28 64 57 9.7
1 2 3 4 5 6 7
Veg28 Liver1 Beans7 Orange3 Incaparina7 Fort oats7 Potato7
7 5 8 8 5 6 7
ok ok ok ok ok ok ok
36 11 9
56 9 9
24
ok ok ok ok ok ok ok
44 64 41 41 69 50 42
71 76 68 68 98 78 74
ok ok ok ok ok ok ok
24 20 37 20 27 22 19
5 315
5 5
16 5 5
39 104 28 29 35 44 28
66 66 67 65 78 79 66
58 60 59 58 76 58 60
10.2 10.0 10.0 9.9
10.1 10.1 9.9
8 5-6 4 ok 9 ok 83 ok ok 36 16 51 ok ok 10.6
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1-2 1-3 1-4 1-7 1-8 2-3 2-4 2-7 2-8 3-4 3-7 3-8 4-7 4-8 7-8
5 7 6 7 4 5 5 5 2 8 7 4 6 4 4
ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok
38 36 82 51 36 11 58 26 11 56 24 9
71 56 24
ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok
68 45 45 46 ok 65 65 66 ok 42 43 ok 44 ok ok
ok ok ok ok ok ok ok ok ok 68 ok ok ok ok ok
ok ok ok ok ok ok ok ok ok ok ok ok ok ok ok
28 46 29 27 44 41 24 22 40 42 40 56 24 40 38
ok 5 5 5
16 ok ok ok ok 5 5
16 5
16 16
ok 39 40 39 62 ok ok ok ok 29 28 51 29 52 51
68 69 66 68 ok 69 67 68 ok 68 69 ok 67 ok ok
60 59 58 60 ok 61 60 62 ok 59 61 ok 60 ok ok
10.5 10.5 10.4 10.5 11.1 10.3 10.2 10.2 10.9 10.2 10.3 10.9 10.1 10.7 10.8
24 25 26 27 28 29 30 31 32
1-2-3 1-2-4 1-2-7 1-2-8 1-3-4 1-3-7 1-3-8 1-4-7 1-4-8
4 4 3 2 6 6 4 6 4
ok ok ok ok ok ok ok ok ok
38 ok 53 38 ok 51 36 ok 37
ok ok ok ok ok ok ok ok ok
69 69 70 ok 46 47 ok 48 ok
ok ok ok ok ok ok ok ok ok
ok ok ok ok ok ok ok ok ok
50 33 31 48 51 49 65 32 44
ok ok ok ok 5 5
16 6
16
ok ok ok ok 40 39 62 40 62
71 68 70 ok 69 71 ok 69 ok
62 60 62 ok 60 62 ok 60 ok
10.8 10.7 10.8 11.3 10.7 10.8 11.3 10.7 11.1
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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# Nutb
<70% RDA Calcium % RDA
Vitamin C % RDA
Thiamin % RDA
Riboflavin % RDA
Niacin % RDA
B6 % RDA
Folate % RDA
B12 % RDA
Vitamin A % RDA
Iron % RDA
Zinc % RDA
Cost GTQ/day
Optimized-A Optimized-B
183 192
110 102
154 157
136 138
179 174
153 140
100 101
356 359
202 198
130 133
97 100
19.2 19.1
Maximizedc 221 219 202 178 216 223 132 364 256 162 106 22.3
Number Recommended 8 103 9 84 40 67 107 16 5 28 64 57 9.7
33 1-7-8 4 ok 51 ok ok ok ok 46 17 62 ok ok 11.2 34 2-3-4 4 ok 58 ok 66 ok ok 46 ok ok 70 61 10.5 35 2-3-7 4 ok 26 ok 67 ok ok 44 ok ok 71 64 10.6 36 2-3-8 2 ok 11 ok ok ok ok 60 ok ok ok ok 11.2 37 2-4-7 4 ok ok ok 68 ok ok 27 ok ok 69 62 10.4 38 2-4-8 2 ok 58 ok ok ok ok 44 ok ok ok ok 11.0 39 2-7-8 2 ok 26 ok ok ok ok 42 ok ok ok ok 11.0 40 3-4-7 4 ok ok ok 45 ok ok 45 5 29 70 61 10.5 41 3-4-8 4 ok 56 ok ok ok ok 61 16 52 ok ok 11.0 42 3-7-8 4 ok 24 ok ok ok ok 58 16 51 ok ok 11.0 43 4-7-8 3 ok ok ok ok ok ok 43 17 52 ok ok 10.9
44 1-2-3-4 2 ok ok ok 70 ok ok 55 ok ok ok 62 11.0 45 1-2-3-7 3 ok 53 ok 71 ok ok 53 ok ok ok 64 11.1 46 1-2-3-8 2 ok 38 ok ok ok ok 68 ok ok ok ok 11.6 47 1-2-4-7 2 ok ok ok 72 ok ok 36 ok ok ok 63 11.0 48 1-2-4-8 1 ok ok ok ok ok ok 52 ok ok ok ok 11.5 49 1-2-7-8 2 ok 53 ok ok ok ok 50 ok ok ok ok 11.5 50 1-3-4-7 5 ok ok ok 49 ok ok 54 6 40 ok 62 11.0 51 1-3-4-8 3 ok ok ok ok ok ok 69 17 63 ok ok 11.5 52 1-3-7-8 4 ok 51 ok ok ok ok 67 17 62 ok ok 11.6 53 1-4-7-8 3 ok ok ok ok ok ok 51 17 63 ok ok 11.4 54 2-3-4-7 3 ok ok ok 69 ok ok 49 ok ok ok 64 10.8 55 2-3-4-8 2 ok 58 ok ok ok ok 64 ok ok ok ok 11.3 56 2-3-7-8 2 ok 26 ok ok ok ok 62 ok ok ok ok 11.3 57 2-4-7-8 1 ok ok ok ok ok ok 46 ok ok ok ok 11.2 58 3-4-7-8 3 ok ok ok ok ok ok 63 17 52 ok ok 11.2
59 1-2-3-4-7 2 ok ok ok 73 ok ok 58 ok ok ok 64 11.3 60 1-2-3-4-8 0 ok ok ok ok ok ok 73 ok ok ok ok 11.8 61 1-2-3-7-8 1 ok 53 ok ok ok ok 71 ok ok ok ok 11.9 62 1-2-4-7-8 1 ok ok ok ok ok ok 55 ok ok ok ok 11.7 63 1-3-4-7-8 2 ok ok ok ok ok ok 72 17 63 ok ok 11.8 64 2-3-4-7-8 1 ok ok ok ok ok ok 67 ok ok ok ok 11.5
65 1-2-3-4-7-8 0 133 99 143 113 130 147 76 327 139 103 85 12.1 a “ok” means that a subset of the set of FBRs tested ensured that ≥ 70% of the RDA was achieved. b number of nutrients < 70% of their RDAs in worst-case scenarios for this FBR. c Refers to maximized diet, that is, a diet following the final set of FBRs in which nutrient intake is maximized.
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Appendix 28. Food Composition Values: Incaparina,a Incaparina-Crecimax,a Vitacereal,b CSBc
Incaparina Incaparina-Crecimax Vitacereal CSB
Food energy kcal/100 g 389.0 427.0 380.0 376.0
Protein g/100 g 21.3 21.0 9.5 17.2
Fat g/100 g 5.3 5.0 4.3 9.7
Carbohydrate g/100 g 64.0 64.0 71.0 61.7
Calcium mg/100 g 299 341.0 200.0 831
Iron mg/100 g 14.9 25.6 14.0 17.49
Zinc mg/100 g 16.0 10.7 8.3 5.0
Vitamin C mg/100 g 0.0 85.0 140 40.0
Thiamin mg/100 g 1.5 1.71 0.36 0.53
Riboflavin mg/100 g 1.7 1.87 0.36 0.48
Niacin mg/100 g 19.2 24.3 6.1 6.23
Vitamin B6 mg/100 g 0.0 2.4 0.44 0.5
Folate µg Dietary Folate Equivalents/100 g 213.0 533.0 83.0 300.0
Vitamin B12 µg/100 g 1.1 3.36 0.52 1.0
Vitamin A RE µg Retinol Equivalents/100 g 213.0 533.0 249.0 784.0
a For Incaparina and Incaparina-Crecimax, the food composition values were calculated from packet information. b For Vitacereal, the food composition values were obtained from a presentation of the WFP given to the Cargill/Fundación Mundial de la Soya II Conferencia de Responsabilidad
Social Empresarial Soluciones Nutricionales para Centroamérica, February 22–23, 2011. Accessed in February 2013.
http://www.worldsoyfoundation.org/news&events/workshops/int/feb2011/PMA-Conferencia-Soya.pdf. c For CSB, the food composition values were obtained from the USAID Food for Peace Commodities Reference Guide. Accessed in February 2013.
http://transition.usaid.gov/our_work/humanitarian_assistance/ffp/crg/.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Appendix 29. Analysis of FBF for Breastfed Children 6–8 Months Old
Nutrients % RDA for breastfed children 6–8 months old when consuming 27 g/day of Incaparina, Incaparina-Crecimax, Vitacereal, or CSBa
# Nutb < 70%
RDA
Calcium Vitamin C Thiamin Riboflavin Niacin B6 Folate B12 Vitamin A Iron Zinc
% RDA % RDA % RDA % RDA % RDA % RDA % RDA % RDA % RDA % RDA % RDA
No Recommendation 10 48.2 49.5 49.3 57.8 31.0 32.2 42.3 51.0 75.0 13.6 22.0
Incaparina 4 65.6 49.5 172.4 166.6 157.0 32.2 114.2 109.9 87.7 51.7 86.9
Incaparina-Crecimax 1 70.5 95.4 200.8 186.7 193.8 254.0 238.8 232.4 107.0 88.5 67.1
Vitacereal 5 59.0 125.1 70.1 75.4 68.7 68.1 66.6 78.6 89.9 49.1 54.0
CSB 3 101.6 71.1 85.5 83.6 69.6 73.6 144.7 104.5 122.0 59.6 39.9
Staple (2 servings/day) + Veg (3 servings/day) +
Incaparina 3 71.7 55.5 177.3 168.9 162.8 50.2 118.1 110.3 90.9 54.5 89.2
Incaparina-Crecimax 1 75.6 101.4 205.5 188.8 199.5 269.0 242.6 232.8 110.1 90.0 69.1
Vitacereal 3 65.0 131.1 75.0 78.0 74.4 87.0 71.0 79.0 93.1 51.8 56.2
CSB 2 107.6 77.1 90.4 86.2 75.3 92.4 149.2 105.0 125.2 62.3 42.1
Staple (2 servings/day) + Veg (4 servings/day) +
Incaparina 3 73.7 63.9 179.7 172.5 165.5 59.1 138.1 110.8 102.2 56.8 91.1
Incaparina-Crecimax 0 77.5 109.8 207.8 192.1 202.3 277.4 262.3 233.3 121.4 92.1 71.0
Vitacereal 3 67.0 139.5 77.3 82.0 77.2 96.1 91.3 79.5 104.4 54.1 58.2
CSB 2 109.6 85.5 92.8 90.2 78.1 101.5 169.5 105.4 136.5 64.6 44.1
Staple (2 s/d) + Veg (4 s/d) + MPE (1 s/d) + Beans (1 s/d) +
Incaparina 2 79.1 63.9 190.5 200.9 171 80.1 184.5 167.2 111.2 65.6 97.5
Incaparina – Crecimax 0 82.4 109.8 215.3 216.2 207.7 298.2 303.5 289.7 130.4 99.6 76.4
Vitacereal 2 72.4 139.5 87.9 110.4 82.6 118.8 137.7 135.9 113.4 62.9 64.5
CSB 1 115 85.5 103.2 118.5 83.5 124.3 215.8 161.8 145.5 73.4 50.3
a cells with nutrients < 70% of their RDAs in worst-case scenarios for this FBR are shaded in gray. b number of nutrients < 70% of their RDAs in worst-case scenarios for this FBR.
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124
Appendix 30. Analysis of FBF for Breastfed Children 9–11 Months Old
Nutrients % RDA for breastfed children 9–11 months old when consuming 30 g/day of Incaparina, Incaparina-Crecimax, Vitacereal, or CSBa
# Nutb
< 70% RDA
Calcium Vitamin C Thiamin Riboflavin Niacin B6 Folate B12 Vitamin A Iron Zinc
% RDA % RDA % RDA % RDA % RDA % RDA % RDA % RDA % RDA % RDA % RDA
No Recommendation 10 47.3 48.9 57.0 63.1 39.5 43.0 45.4 51.0 80.9 16.4 22.9
Incaparina 4 68.5 48.9 194.1 182.8 174.4 43.0 122.5 116.3 95.1 60 95.8
Incaparina-Crecimax 0 72.6 99.9 225.3 204.7 222.0 304.3 259.5 253.0 116.5 100.5 73.0
Vitacereal 3 61.1 132.9 80.4 81.4 76.3 78.1 70.6 81.5 97.4 57.1 59.2
CSB 2 108.4 72.9 97.5 90.5 77.3 84.2 157.4 110.3 133.1 68.8 43.5
Staple (2 servings/day) + Veg (3 servings/day) +
Incaparina 3 75.5 62.8 201.8 186.5 183.9 64.3 135.2 117.2 97.8 63.3 100.3
Incaparina-Crecimax 0 85.5 106.4 234.0 206.8 226.0 323.3 262.6 253.6 118.1 106.1 78.8
Vitacereal 3 68.1 146.8 88.1 85.5 85.7 104.2 83.3 82.4 100.2 60.4 63.7
CSB 1 115.4 86.8 105.3 94.6 86.7 110.2 170.1 111.2 135.9 72.1 48.0
Staple (2 servings/day) + Veg (4 servings/day) +
Incaparina 0 86.0 89.4 208.7 203.6 190.4 96.9 170.3 117.8 116.8 84.0 103.9
Incaparina-Crecimax 0 89.7 140.4 239.8 224.9 232.8 348.4 304.8 254.1 138.1 124.0 80.2
Vitacereal 1 78.6 173.3 95.0 103.0 92.2 137.5 118.3 83.1 119.2 81.1 67.2
CSB 1 125.9 113.3 112.1 112.1 93.2 143.5 205.2 111.9 154.8 92.8 51.5
Staple (2 s/d) + Veg (4 s/d) + MPE (1 s/d) + Beans (1 s/d) +
Incaparina 0 84.8 173.5 105 129.2 95.6 162.6 168.2 133.2 126.3 92.1 74.9
Incaparina – Crecimax 0 95.3 140.5 239.5 242.2 231.9 358.5 348.2 303.6 145.2 130.7 86.2
Vitacereal 0 84.8 173.5 105.0 129.2 95.6 162.6 168.2 133.2 126.3 92.1 74.9
CSB 1 132.1 113.5 122.0 138.2 96.7 168.6 255.0 162.1 162.0 103.8 59.2
a cells with nutrients < 70% of their RDAs in worst-case scenarios for this FBR are shaded in gray. b number of nutrients < 70% of their RDAs in worst-case scenarios for this FBR.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
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Appendix 31. Target Usual Intake Distribution of Iron for Breastfed Children 6–8 Months
Panel A
Panel B
Panel A shows the baseline usual nutrient intake distribution, based on the dietary analysis of the cross-
sectional survey data, as compared to the EAR distribution and RDA. The mean iron intake is 2.6 mg/d
and the 5th percentile of iron intake is 0.4 mg/d.
Panel B shows the shift up of the entire baseline distribution such that the worst-case scenario level (i.e.,
the 5th percentile) is ≥ 70% of the RDA. The mean iron intake of the target usual intake distribution is
8.5 mg/d and the 5th percentile of iron intake is 6.3 mg/d.
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
126
Appendix 32. Participant Selection Form for Pregnant and Lactating Women
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
127
Appendix 33. Participant Selection Form for Children 6–23 Months of Age
Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands of Guatemala
128
Appendix 34. Survey Form for Family Demographic, Health, Diet, Food Security, and Nutritional Status of Women and Children
Nutrition Institute of Central America and Panama — INCAP
PROTOCOL: DEVELOPMENT OF EVIDENCE-BASED DIETARY INTAKE RECOMMENDATIONS FOR CHILDREN
AGED 6-23 MONTHS AND PREGNANT AND NURSING MOTHERS IN THE WESTERN HIGHLANDS OF
GUATEMALA USING OPTIFOOD SOFTWARE AS A CONTRIBUTION TO FOOD-BASED APPROACHES FOR
IMPROVING NUTRITION. (PROTOCOL NUMBER: CIE-012-11).
FORM #3: FAMILY DEMOGRAPHICS, HEALTH, DIETARY PRACTICES, HEALTH,
FOOD SECURITY AND CHILD’S NUTRITIONAL STATUS INSTRUCTIONS: This form must be completed by project personnel by interviewing mothers who have given their consent
to participate. If the mother has not signed the informed consent, PLEASE DO NOT GO AHEAD WITH THE
INTERVIEW.
SECTION I: GENERAL DATA
1.1 Mother’s ID (assigned code): Participating child’s ID (assigned code)
# M_____________________; Initials: _______ # C_____________________; Initials: _______
1.2 Health Center ID card number: #_____________________; Does not have one: ________
1.3 Name of the Community:
1|__] Cunén, Quiché 2|__] Nebaj, Quiché 3|__] Chajul, Quiché 4|__] Cotzal, Quiché 4|__] Sacapulas, Quiché 5|__] San Sebastián Huehuetenango
6|__] San Pedro Nécta 7|__] Chiantla, Huehuetenango 8|__] Todos Santos, Huehuetenango 9|__] San Miguel Ixtahuacán, San Marcos 10|__] Other; specify:
1.4 Conglomerate to which the interviewed family belongs:
1|__] Association of Agricultural Producers 2|__] Community in general
1.5 Place of assessment: 1|__] Home/residence 2|__] Health Center or Post 3|__] Other; specify: _____________________________
1.6 Date of assessment: dd________; mm:__________; Year: 2012
SECTION II: POPULATION DATA (Interview with the child’s mother or guardian)
2.1 Please tell me your date of birth.
a[__|__] day b[__|__] month c[__|__][__|__|year d|__] Does not know
2.1A How old are you? 1[__|__] years completed 2|__] Does not know
2.1B What is your marital status? 1|__]Married 2|__] Living together 3|__]Single 4|__] Other; specify _______________
2.2 ETHNIC GROUP (ONLY BY OBSERVATION)
1[__| Indigenous 2[__| Ladina 1[__| Other; specify: _____________
2.2A Do you speak Spanish? 1|__]Yes; 2|__]No
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2.2B What is your mother tongue? 1[__| Spanish 2[__| Quiché 3[__| Ixil
4[__| Mam 5[__| Other; specify
2.2C In what language was the interview conducted?
1[__| Spanish 2[__| Quiché 3[__| Ixil
4[__| Mam 5[__|Other; specify
2.3.
How many children under five do you have? How old are they? 2.3.1. Number of children: _______
2.3A How old are they? (FROM THE YOUNGEST TO THE OLDEST) 1|__] _______ months 2|__] years_______; months: ______ 3|__] years_______; months: ______ 4|__] years_______; months: ______
2.4 Do you do paid work? 1|__]Yes; 2|__]No
2.5 Do you participate in agricultural activities outside the home, either for sale or for your own consumption?
1[__|Yes, I work in the fields at least one day a week 2[__|Yes, I work in the fields 1-3 days a week 3[__|Yes, I work in the fields 4-7 days a week 4[__| I do not work in agriculture or for crops
2.6 Does your family have a garden plot (for growing vegetables) either for sale or for your own consumption?
1[__|Yes, mainly for sale 2[__|Yes, mainly for consumption 3[__|Yes, enough is grown for sale and for consumption 4[__| There is no family vegetable garden. GO TO Q.2.8 If 1, 2 and 3 were answered, go to the next question.
2.7 What types of crops are grown in the family vegetable garden?
1[__|_________________________ 2[__|_________________________ 3[__|_________________________ 4[__|_________________________ 5[__|_________________________
2.8 Does your husband participate in agricultural activities, either for sale or for consumption?
1[__|Yes, he works in the fields at least one day per week 2[__|Yes, he works in the fields 1-3 days a week 3[__|Yes, he works in the fields 4-7 days a week 4[__| He does not work in agriculture or crops. GO TO Q 2.10
2.9 Do you own or rent the land used for farming by your family (i.e. you and your husband)?
1[__| Own 2[__| Belongs to the parents; no rent is paid 3[__| Belongs to somebody else; no rent is paid 4[__| Belongs to somebody else; rent is paid
2.10 Do you raise domestic animals in the household?
1[__|Yes 0[__|No GO TO QUESTION 2.13
2.11 What animals? EXPLORE: Any other animals?
1[__| Hens, chickens or other barnyard fowl 2[__| Rabbits 3[__| Pigs 4[__| Sheep or goats 4[__| Cows and heifers 4[__| Other; specify: _____________
2.12
What do you do with the animals you raise or the products of those animals? GIVE EXAMPLES, SUCH AS MILK,
CHEESE, BUTTER, MEAT, EGGS, ETC.
1[__| Mainly for family consumption 2[__| Mainly for sale 3[__| There is enough for both consumption and sale 4[__| Does not know
2.13 Do you depend on the income of other household members?
1[__|Yes 0[__|No
2.14 Is the house where you live …?
1[__|Your own 2[__|A rented house 3[__|A rented room or apartment 4[__|Other; specify __________________________
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2.15 Main flooring material ONLY BY OBSERVATION
1|__] natural (earth/sand) 2|__] rustic flooring (boards) 3|__] clay or earthen tiles 4|__] polished wood
5|__] cement tiles (mosaic), terrazzo 6|__] ceramic tiles 7|__] cement slab 8|__] Other; specify:
2.16 Main roofing material ONLY BY OBSERVATION
1|__] straw/thatch/palm 2|__] tile 3|__] zinc/sheet metal 4|__] asbestos sheets (Duralita®) 5|__] concrete/slab/terrace 6|__] Other; specify_____________________;
2.17
Main wall material ONLY BY OBSERVATION (Consider waste materials such as cardboard, plastic, aluminum)
1|__] mud 2|__] adobe 3|__] blocks 4|__] sheet metal
5|__] lumber 6|__] clay tiles 7|__] waste material 8|__] Other; specify:
2.18 Do you have electricity at home? 1|__] Yes there is electricity service 2|__] No
2.19 What APPLIANCES do you have at home? (CHECK ALL THOSE THAT APPLY).
1|__] Manual mill 2|__] Radio 3|__] TV 4|__] Cable TV 5|__] Home telephone (land line) 6|__] Mobile telephone
7|__] Refrigerator 8|__] Blender 9|__] Washing machine 10|__] Microwave oven 11|__] Computer
2.20
Which of the following VEHICLES do you have at home? (CHECK ALL THOSE THAT APPLY)
1|__] Bicycle 2|__] Motorcycle
3|__] Car 4|__] Pickup truck
2.21 How do you get your water during most of the year?
1|__] Piped (indoor) inside the home 2|__] Truck 3|__] Public open-air faucet for several families 4|__] River, lake, stream or creek 5|__] Well 6|__] Other; specify ___________________________
2.22
What do you do to purify or clean the
water you drink?
(CHECK ALL THOSE THAT APPLY)
1|__] Boil it 2|__] Chlorinate it 3|__] Place it in the sun (sodis method) 4|__] Nothing 5|__] Other; specify ___________________________
2.23 What type of toilet facilities do you have at home?
1|__] private toilet connected to sewer 2|__] shared toilet connected to sewer 3|__] toilet connected to septic tank 4|__] improved latrine (implemented by NGO) 5|__] latrine, outhouse 6|__] has no toilet facilities 7|__] other; specify ___________________________
2.24 What type of fuel do you use for
cooking most of the time at home?
1|__] propane gas 2|__] kerosene 3|__] electricity 4|__] firewood
5|__] charcoal 6|__] agricultural waste 7|__] other; specify
2.25 How many people live in your home?
2.26 How many bedrooms are there in your home?
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2.27
What is your highest educational level? DID YOU ATTEND PRIMARY OR SECONDARY SCHOOL?
1|__]Primary: grades passed ______ 2|__]Secondary: grades passed ______ 3|__]After high school: grades passed ______ 4|__] Did not go to school, but can read and write 5|__] Did not go to school, cannot read and write
SECTION III: PARTICIPATING CHILD’S HEALTH AND DIET
3.1
3.1.1. Sex of the boy/girl: 3.1.1. Date of birth: 3.1.2.Age of the child: 3.1.3.Verification of child’s age (MARK WITH AN “X” AS APPLICABLE)
1|__] Male; 2|__] Female
Day:____; month:_____; year_____
________ full months
1|__] Mother’s report; 2|__] Health card; 3|__] Birth certificate
3.2 Has a doctor or health practitioner told you that your baby was born prematurely or small for the length of the pregnancy?
1|__] a) Premature _________number of months before the expected delivery date;
b) Weight at birth ______.____kg 2|__] a) Small, but born on the due date (9 months); b) weight at birth _____.____kg 3|__] Neither premature nor small for the length of the pregnancy 4|__] Does not know
3.3 Has a doctor or health practitioner told you that your baby has a chronic disease or condition (since birth or for a long time)?
1|__] Yes; specify:_________________________ 0|__] No
3.4 During the last two weeks, how have you seen the child’s health?
1|__] Apparently healthy (without symptoms or signs of disease and the baby’s mother thinks he/she looks healthy) 2|__] Is now recovering from an acute illness suffered during the last two weeks (cold, diarrhea, fever, etc.); 3|__] Has had an illness for more than three weeks: diarrhea, vomiting, cough, skin rash, fever, etc.)
3.5
Which of the following options best describes the way you feed your son/daughter? ASK IF THE CHILD IS BREASTFED, GIVEN LIQUID OR SOLID FOOD, INFANT FORMULA OR WHOLE MILK.
1|__] Only breast milk (no fluids or solid foods, except for medicine) 2|__] Breast milk and other fluids (including formula) 3|__] Breast milk, other fluids and solid food 4|__] Stopped breastfeeding; only formula 5|__] Formula and solid foods 6|__] Only solid and liquid foods (does not receive breast milk or formula). (If you marked option 1, 2 or 3 go to question 3.7)
3.6 Presently are you nursing (breastfeeding) your child?
1|__] YES, GO TO Q 3.6B 2|__] NO
3.6A How old was the child when you stopped nursing him/her?
__________ full months GO TO 3.7
3.6B Do you remember how many times you nursed the baby yesterday?
# _____times during the day #_____ times during the night
3.7 At what age did you start giving him/her fluids or solid foods?
1|__] Some fluid (includes brews): _______months 2|__] First solid food: _____ months
3.8 When you (the mother) works or is out of the house, who takes care of ___________ (the child)?
1|__] The mother takes the child with her 2|__] A family member 3|__] A neighbor/friend 4|__] The child is left alone; nobody takes care of the child 5|__] Does not work outside the home 6|__] Does not know/does not remember/does not answer 7|__] Other: (specify) ___________________________
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3.9 Has (NAME) been weighed or measured during the last 12 months?
1|__] YES 2|__] NO
3.10 Where is (NAME) weighed or measured?
1|__] At home 2|__] Community/convergence center 3|__] Health post
4|__] Health center 5|__] Hospital 6|__] Other
3.11 The last time that (NAME) was weighed, were you told he/she had the right weight or low weight?
1|__] Yes, she was told the child’s weight was OK 2|__] Yes, she was told the child’s weight was low 3|__] Yes, she was told but does not remember 4|__] She was not told
3.12 The last time (NAME) was measured, were you told he/she was growing well?
1|__] Yes, she was told the child’s length was OK 2|__] Yes, she was told the child’s length was inadequate or that
he/she needed to grow more 3|__] Yes, she was told but does not remember 4|__] She was not told
3.13 And do you think your child is growing well? 1|__] YES 2|__] NO
3.14
The last time (NAME) was weighed or measured, did they tell you or advise you on the best way to feed and take care of your child?
1|__] YES 2|__] NO 3|__] DOES NOT REMEMBER
3.14A Has your child received the vaccines at the health center or post?
1|__] Yes, he/she has received all the vaccines for his/her age 2|__] He/she has received some shots, but has not completed all the shots for his/her age 3|__] He/she has not been immunized
3.15 During the last 24 hours, did (NAME) take vitamins such as …?
1|__] Ferrous sulfate 2|__] Vitamin A 3|__] Folic acid 4|__] Sprinkles 5|__] RUTF (ready to use therapeutic food) 6|__] Other; specify: _______________________
3.16 Does your family receive aid in the form of food, inputs or cash? CHECK ALL THOSE THAT APPLY.
1|__] Government safety kit 2|__] Vitacereal 3|__] NGO sponsorship program 4|__] Zero Hunger 5|__] Fertilizers 6|__] Family remittances from abroad 7|__] Other; specify: _______________________
3.17 Was yesterday a community holiday? 1|__] YES 2|__] NO
3.18 Was yesterday a family holiday? 1|__] YES 2|__] NO
SECTION IV: PREGNANT WOMEN’S HEALTH AND DIET (IF THE MOTHER IS NOT PREGNANT, GO TO SECTION V, NURSING MOTHER)
4.1
4.1.1. Do you remember how many months pregnant you are? 4.1.2. How much time has elapsed since your youngest son/daughter was born?
________ full months (SINCE THE DATE OF THE LAST PERIOD). _____ full years_____ months (YOU CAN ASK HOW OLD THE YOUNGEST CHILD IS)
4.2 Have you had prenatal checkups? 1|__] Yes 0|__] No Go to 4.9
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4.3 How many months pregnant were you when you had your first prenatal checkup?
_______ full months
4.4 Where did you get your prenatal checkup?
1|__] Health post 2|__] Health center 3|__] Convergence center 4|__] CAIMI care center 5|__] Permanent Care Center (CAP)
6|__] Hospital 7|__] Private Clinic 8|__] Home (of the interviewee or midwife) 9|__] Other. Specify
4.5 Do you have a health card where visits to the health center or post are written down?
1|__] YES 0|__] NO
4.6 What provider gave you your prenatal checkup?
1|__] Doctor 2|__] Nurse 3|__] Midwife
4|__] Community medicine man 5|__] Other; specify:
4.7 Were you told your pregnancy is progressing well?
1|__] Yes, it’s OK 0|__] No, it’s not OK; specify:
4.8 The last time you went for a prenatal checkup, did they tell you or advise you on the best diet during pregnancy?
1|__] YES 2|__] NO 3|__] DOES NOT REMEMBER
4.9 Since you became pregnant, is the amount of food you eat every day …
1|__] the same as before 2|__] you are eating more 3|__] you are eating less
4.10 Since you became pregnant, is the type of food you eat every day …
1|__] the same as before 2|__] You are eating more of certain foods 3|__] You are eating less of certain foods
4.11 Have you received vitamin supplements from health care providers?
1|__] Yes 0|__] No
4.12 During the last month, have you been taking vitamins regularly, such as …? CHECK ALL THOSE THAT APPLY.
1|__] Ferrous sulfate (weekly) 2|__] Folic acid (weekly) 3|__] Prenatal vitamins (daily) 4|__] Sprinkles (daily) 5|__] RUF (ready to use therapeutic food) (daily) 6|__] Other; specify: _______________________
4.13 Are you currently breastfeeding (nursing) a small child?
1|__] Yes 0|__] No Go to Q 4.15
4.14 If you are breastfeeding (nursing), how many times did you breastfeed yesterday?
# _____ times during the day #_____ times during the night
4.15 If you are pregnant ant and have a small child that you are breastfeeding (nursing), you …
1|__] Stop breastfeeding immediately 2] __] Continue breastfeeding until the baby is 6 months old 3|__] Continue breastfeeding until the baby is a year old 4|__] Will continue breastfeeding until the baby is two 5|__] Will continue breastfeeding until the baby stops asking
4.16 Do you consider that your diet was “normal” yesterday? …
1|__] The same as every day 2|__] You ate more than other days 3|__] You ate less than other days
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SECTION V: NURSING MOTHERS’ HEALTH AND DIET
5.1 5.1.1. Can you tell me how long it has been since your last delivery? 5.1.2. How long has it been since your last child was born?
A)_____ years _____ B) full months (YOU CAN ASK HOW OLD THE LAST CHILD OR THE YOUNGEST CHILD IS)
5.2 Have you had postpartum checkups? 1|__] Yes 0|__] No Go to 5.6
5.3 Where did you get your postpartum checkup?
1|__] Health post 2|__] Health center 3|__] Convergence center 4|__] CAIMI care center 5|__] Permanent Care Center (CAP)
6|__] Hospital 7|__] Private Clinic 8|__] Home (of the interviewee or midwife) 9|__] Other. Specify:
5.4 Which provider gave you your postnatal checkup? 1|__] Doctor 2|__] Nurse 3|__] Midwife
4|__] Community medicine man 5|__] Other; specify:
5.5 The last time you went for a postnatal checkup, did they explain or advise you on the best diet you should have after giving birth and breastfeeding?
1|__] YES 2|__] NO 3|__] DOES NOT REMEMBER
5.6 After you had your last child, is the amount of food you eat every day …
1|__] the same as before 2|__] you are eating more 3|__] you are eating less
5.7 After you had your last child, is the type of food you eat every day …
1|__] the same as before 2|__] You are eating more of certain foods 3|__] You are eating less of certain foods
5.8 Have you received vitamin supplements from health care providers alter your last delivery?
1|__] Yes 0|__] No
5.9 During the last month, have you been taking vitamins regularly, such as …? CHECK ALL THOSE THAT APPLY.
1|__] Ferrous sulfate (weekly) 2|__] Folic acid (weekly) 3|__] Prenatals (daily) 4|__] Sprinkles (daily) 5|__] RUTF (ready to use therapeutic food) (daily) 6|__] Other; specify:
5.10 Do you consider that yesterday your eating was “normal” ? 1|__] The same as every day 2|__] You ate more than other days 3|__] You ate less than other days
SECTION VI: PERCEPTION OF FOOD SECURITY IN THE HOME
6-4.1
During the last 30 days, did you ever worry that food would run out before you would have money to buy more food? 1|__] YES; 2|__] NO -->
1|__] Rarely (1-2 times) 2|__] Sometimes (3-10 times) 3|__] Frequently (more than 10 times)
6.2 During the last 30 days, were you or a member of your family unable to eat nutritious foods of animal origin such as eggs or meat because you could not afford them? 1|__] YES; 2|__] NO -->
1|__] Rarely (1-2 times) 2|__] Sometimes (3-10 times) 3|__] Frequently (more than 10 times)
6.2a During the last 30 days, were you unable to give your children nutritious foods of animal origin such as eggs or meat because you could not afford them? 1|__] YES; 2|__] NO -->
1|__] Rarely (1-2 times) 2|__] Sometimes (3-10 times) 3|__] Frequently (more than 10 times)
6.3 During the last 30 days, did you or a member of your family have to eat a limited variety of foods because there was not enough money to buy food? 1|__] YES; 2|__] NO -->
1|__] Rarely (1-2 times) 2|__] Sometimes (3-10 times) 3|__] Frequently (more than 10 times)
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6.4 During the last 30 days, did you or a member of your family have to eat foods you didn’t really like because there was not enough money to buy food? 1|__] YES; 2|__] NO -->
1|__] Rarely (1-2 times) 2|__] Sometimes (3-10 times) 3|__] Frequently (more than 10 times)
6.5 During the last 30 days, did you or a member of your family have to eat less than you thought you needed, because there was not enough money to buy food? 1|__] YES; 2|__] NO -->
1|__] Rarely (1-2 times) 2|__] Sometimes (3-10 times) 3|__] Frequently (more than 10 times)
6.6 During the last 30 days, did you or a member of your family have to skip a meal because there was not enough money to buy food? 1|__] YES; 2|__] NO -->
1|__] Rarely (1-2 times) 2|__] Sometimes (3-10 times) 3|__] Frequently (more than 10 times)
6.7 During the last 30 days, was there a time when there was no food at all at home because there was no money to buy food? 1|__] YES; 2|__] NO -->
1|__] Rarely (1-2 times) 2|__] Sometimes (3-10 times) 3|__] Frequently (more than 10 times)
6.8 During the last 30 days, did you or a member of your family go to bed hungry (without dinner) because there was no money to buy food? 1|__] YES; 2|__] NO -->
1|__] Rarely (1-2 times) 2|__] Sometimes (3-10 times) 3|__] Frequently (more than 10 times)
6.9 During the last 30 days, did you or a member of your family go without any food at all for a whole day and night because there was no money to buy food? 1|__] YES; 2|__] NO -->
1|__] Rarely (1-2 times) 2|__] Sometimes (3-10 times) 3|__] Frequently (more than 10 times)
SECTION VII: ANTHROPOMETRIC ASSESSMENT OF THE INFANT AND MOTHER (Two Measurements)
CHILD MOTHER
Measurement 1 2 1 2
7.1 Weight (0.1 kilograms)
7.2 Length/Height (0.1 cm)
7.3 BMI (estimated, 0.1 kg/sq m)
7.4 Equipment used for anthropometric measurements:
7.4.1 Scale 1|__] Scale: assigned code:_________ 2|__] Scale different from the one assigned for the project (specify the reason for the equipment change in comments)
7.4.2 Measuring tape 1|__] Measuring tape: assigned code: _________ 2|__] Measuring tape different from the one assigned for the project (specify the reason for the equipment change in comments)
7.5 Was the child weighed with or without clothing?
1|__] Clothed; --> 7.5.1.1 |__] Minimum amount of clothing 7.5.1.2 |__] Fully clothed
2|__] Without clothing 7.5.1.3 |__] Weight of the clothing: ______.____kg
7.6 Relevant comments related to the interview:
1|__] NO; GO TO Q P 7.7 2|__] YES;
7.7 Interview and assessment date: dd_____ mm______ year______
7.8 Interviewer: ID:__________; first name: ____________
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Appendix 35. INCAP 24-Hour Dietary Recall Forms
FORM #4. 24-HOUR DIETARY RECALL
CHILD’S ID CODE:____________; MOTHER’S ID CODE:____________ Page 1 of 2
Instructions:
Help her remember yesterday based on the time the child got up, activities she had, etc. Go little at a time.
Ask: I want you to tell me everything your child ate and drank yesterday.
After the child got up, what was the first thing you gave him/her to eat or drink?
After that, what other food did you serve him/her?
Write down all the foods or preparations eaten the day before that the mother/caregiver mentions.
Don’t forget to ask, “What do you call that meal (e.g. breakfast, lunch, dinner, between-meal snack)?
FORM #4. 24-HOUR DIETARY RECALL
CHILD’S ID CODE:____________; MOTHER’S ID CODE:____________ Page 2 of 2
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24-HOUR RECALL FORM PARTICIPATING CHILD’S CODE: ______________PARTICIPATING MOTHER’S CODE: _____________
Mealtime Name of food or preparation
Ingredients (specify characteristics) OFFICE Measurements obtained at the household
Conversion to grams
NET GRAMS
Ingredient Characteristic Food or Preparation Code Served
Not eaten Eaten
Weight 1=Gross 2=Net
Ingested form 1 = Raw 2 = Cooked Served Eaten
Mealtime: Breast milk: 00; Main meals: 10 morning (breakfast), 20 noon (lunch) 30 evening (dinner); Snacks: 01, 02, 03… morning (before breakfast); 11, 12, 13…: morning (after breakfast); 21, 22, 23…: afternoon 31, 32, 33…:evening
Preparation: Total weight of cooked ingredients: Preparation Total weight of cooked ingredients:
Ingredients Amount used:
Weight 1 = Gross 2 = Net
Form used 1 = Raw 2 = Cooked
Conversion to cooked Grams cooked Ingredients
Amount used
Weight 1 = Gross 2 = Net
Form used 1 = Raw 2 = Cooked
Conversion to cooked Grams cooked
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Appendix 36. Instructions for 24-Hour Dietary Recall (Spanish)
INSTRUCTIVO DEL FORMULARIO DE CONSUMO DE ALIMENTOS RECORDATORIO DE 24 HORAS54
1. INTRODUCCION
Para la planificación de programas nutricionales s requiere de un buen conocimiento de los problemas que
afectan una población en donde se quiere intervenir. Los problemas nutricionales pueden aparecer a nivel
del hogar, tal es el caso de la falta de recursos para adquirir alimentos o bien una baja o sobre ingesta de
nutrientes a nivel individual. La utilidad de las encuestas alimentarias para la obtención de este
conocimiento, es muy amplia y valiosa.
Existen diversos métodos para realizar estudios sobre consumo de alimentos, ya sea de individuos, familias
o grupos. El presente estudio utilizara como referencia la “GUIA METODOLOGIA PARA REALIZAR
ENCUESTAS FAMILIARES DE CONSUMO DE ALIMENTOS,” preparada por la Licda.M.T, Menchu.
Uno de los métodos utilizados para determinar el consumo familiar e individual es el Recordatorio de 24
horas. Este método consiste en registrar, mediante una entrevista, todos los alimentos consumidos por los
miembros del hogar o por el individuo en estudio, el día inmediato anterior. Este método comparado con
otros más complejos, ofrece una alternativa para obtener buena información con relativa facilidad de
aplicación.
Este método requiere que los entrevistadores estén familiarizados con los tipos de preparaciones que
acostumbra consumir la población en estudio y que puedan juzgar apropiadamente la veracidad de las
cantidades indicadas, a fin de obtener información de buena calidad. También requiere mucha habilidad
por parte del encuestador(a) para que pueda facilitar la memoria de la persona entrevistada y evitar sesgos
y omisiones.
Cada encuesta dietética tiene sus propios propósitos y énfasis, por lo tanto, tendrá un formato distinto. En
este estudio el énfasis está en la dieta de familias y niños(as) de 6 a 23 meses de edad. Esta información nos
ayudara evaluar la calidad de las dietas de las personas entrevistadas, así como a determinarla adecuación
de la energía, macro y micronutrientes del grupo de niños y niñas de 6 a 23 meses de edad así como mujeres
embarazadas y lactantes.
Se considera ideal realizar entrevistasen tres días no consecutivos para determinar la ingesta “Usual” de
energía y nutrientes pero debido a los costos y los recursos disponibles, pueden realizarse dos entrevistas
en días no consecutivos para recolectar la información delas familias y registrar el consumo individual de
por lo menos un niño de 6 a 23 meses de edad en el momento del estudio.
A continuación se presenta un listado del equipo y materiales que las encuestadoras deben llevar a todas las
entrevistas.
- Formularios -Bolso -Tabla con prensa
- Lápiz -Calculadora de bolsillo -Servilletas de papel
- Sacapuntas -Taza medidora -Balanza dietética
- Borrador -Juego de 4 cucharas
54 Méndez, H. Instructivo del formulario de consumo de alimentos. Recordatorio de 24 horas, INCAP, 2012 (documento interno).
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LLENADO DEL FORMULARIO
Técnica de la entrevista
En una encuesta de consumo de alimentos, la utilización correcta de la técnica de entrevista ayudara a
disminuir las barreras que existen, ya que la alimentación es un aspecto íntimo de la familia el cual denota
su nivel social, económico y cultural. Una entrevista sobre consumo de alimentos se debe realizar en el
hogar y mejor si es dentro dela cocina. No realice la entrevista en presencia de personas ajenas a la
familia, tales como los vecinos o visitas. Si la persona entrevistada tiene que interrumpir un momento la
conversación para atender su hogar, deje que lo haga. Hable con soltura, utilizando un lenguaje claro y
adecuado al nivel del entrevistado(a). Sea amable, adoptando una actitud de solicitud y no de imposición.
Utilice un tono de voz moderado, sea natural. Es esencial que todos los(as) encuestado(as) actúen según las
instrucciones, lo cual asegura que la información se recolecte en una forma estandarizada. Sea
observador(a) y anote cualquier observación que influya en el desarrollo de la entrevista y la recolección
de datos.
Cuando llegue al hogar, pregunte por la persona que prepara la comida al infante, con ella haga la entrevista
siempre. Si está el jefe(a) de la familia, salude, preséntese y explique el objetivo de la visita de igual forma
si llega el jefe(a) de la familia durante la entrevista. Un ejemplo de presentación es el siguiente:
“Buenos días, mi nombre es ___ _________ del Instituto de Nutrición de Centro América y Panamá
están realizado un estudio en esta comunidad y vengo a visitarla para conversar sobre los alimentos
que usted prepara para su familia y los niños y niñas. Si me permite le voy a hacer algunas preguntas
sobre lo que ustedes comieron el día de ayer: desde que se levantaron hasta que se fueron a dormir.
No influya en las respuestas al formular las preguntas. Estas deben ser neutras. Por ejemplo: ¿Cómo
preparo su café? O ¿Qué puso en el café? NO DIGA ¿Cuánto le puso de azúcar al café? O ¿Cuánto uso de
aceite para el huevo frito? No influya en las respuestas con sus actitudes, expresiones faciales y
comportamiento. Por ejemplo, no muestre expresión de malestar cuando tiene que repetir las preguntas
por que la persona no comprende, ni tome una actitud de sorpresa cuando uso demasiado azúcar para el
café o leche del niño o niña.
Debe tener paciencia. No es necesario preguntar y hablar sin parar. Las pausas permitirán que la persona
entrevistada piense y sienta más confianza, al mismo tiempo no se satisfaga con respuestas superficiales.
Es responsabilidad del encuestador(a) conseguir toda la información necesaria para llenar el formulario
completamente y en forma comprensible un buen encuestador sabe manejar una entrevista, escuchando al
informante para obtener la información en forma eficiente. Una entrevista que tarda demasiado tiempo
causa molestia al infórmate y es ineficiente para el trabajo del encuestador(a).
Instrucciones para llenar el formulario
Utilice lápiz para hacer las anotaciones, escriba con precisión adecuada para que no se vea borroso, haga
letra y números legibles, borre completamente cuando se halla equivocado porque si no lo hace no queda
claro lo que escribe después. Para cumplir con estas indicaciones no olvide que debe escribir con lápiz, deje
líneas entre recetas para que la información en el formulación no aparezca muy cargada. El manejo limpio
y ordenado de todos los formularios es necesario porque en el centro de cómputo deben entender
correctamente todo lo que está registrado en los mismos, para su correcto procesamiento. Recuerde que las
personas que utilizan los formularios después no estuvieron presentes durante la entrevista y todo tiene que
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quedar completamente claro, lo que parece obvio en el momento, a veces no es obvio para quien no estuvo
presente.
El Supervisor(a) del equipo de campo revisara los formularios en las comunidades, haciendo las
correcciones pertinentes en color rojo si es necesario se deberá regresar a la casa para completar alguna
información. Si algún error es detectado en el centro de cómputo en el momento de ingreso de los datos,
este formulario será entregado al supervisor para que lo corrija y pueda continuarse con la digitación del
mismo.
El formulario contiene 13 columnas alguna de ellas tiene un símbolo (▼) en la parte superior para indicar
que pueden ser llenadas en la oficina; otras están sombreadas para indicar que estas columnas no serán
digitadas.
Localización
Fecha: Anote la fecha exacta de cuando se realiza la entrevista utilizando dos dígitos para el día, mes y
año. Ejemplo: Una entrevista realizada el 6 de junio del 2012 se debe registra si/06/06/12/.
Nombre de la Madre entrevistada: Escriba el nombre y apellidos de la madre o cuidadora que suministra
la información de la encuesta de consumo de alimentos en el día de la entrevista.
Teléfono: Anote el número de teléfono correspondiente según el formulario.
Nombre del niño o niña: Escriba el nombre y los apellidos del niño o niña según el formulario.
Nombre del encuestador: Escriba su nombre y dos apellidos
Código: Anote el código de identificación que le fue dado previamente.
Identificación
Hoja No.____de____
Indique el número de hoja del total de hojas de la entrevista.
Ejemplo: si en una entrevista utiliza 5 hojas en la primera anote hoja No.1 de 5 en la segunda anote, hoja
No. 2 de 5 y así sucesivamente hasta llegar hasta la última hoja No. 5 de 5.
Todas las hojas de una entrevista deben estar completamente llenas como se indicó anteriormente.
Recuerde que existe la posibilidad que una hoja se desprende del resto y si no tiene toda la
información, será imposible ubicarla en un lugar adecuada ocasionando perdida de información.
Luego inicie la entrevista preguntando por lo consumido durante el desayuno y anote en el formulario de
acuerdo al siguiente orden:
1. Nombre del alimento de la preparación: Anote en esta columna Desayuno y empiece a listar todas las
preparaciones y alimentos que comieron durante el desayuno. Luego regrese a la primera preparación
y pregunte en orden y anote en el numeral de la columna de la siguiente forma :
2. Tiempo de comida: Anotar paralelamente a la entrevista
3. Alimentos usados en la preparación (nombre, tipo, color, tamaño, marca)
4. Cantidad usada
5. Código dela unidad de medida. En el caso que registre información de diferentes medidas o tamaños
de alimentos
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6. Número total de porciones
7. Porciones no consumidas
8. Cantidad servida
9. Sobras
Nota: Este no es el orden que llevan las columnas en el formulario sino la forma de conducir la entrevista
para que le facilite anotar la información en el formulario.
Ejemplo de entrevista:
1. Señora, ¿que comieron para el desayuno? anotar en la columna 1 (nombre de la preparación) las
preparaciones y/o alimentos solos que comieron para ese tiempo de comida.
2. ¿Cómo preparo los huevos? (anote los ingredientes en la columna 5: nombre, tipo).
3. Cuanto de cada ingrediente: ¿cuantos huevos?, ¿De qué tamaño? (continúe escribiendo la cantidad
usada, el tamaño del alimento o la medida usada en la columna 6.
4. De esta preparación o alimento (ej. huevos) comió el niño o niña seleccionado. Si la respuesta es
afirmativa, continuar preguntado:
5. ¿Cuantas porciones le salieron de esta preparación?
6. ¿Cuánto comió el niño o niña? Sobre la base del total de las porciones preparadas: ¿Cuánto le sirvió al
niño o niña?
7. ¿Cuánto sobro? (se refiere a lo que sobro de la preparación o alimento de la “dieta familiar” y también
lo que dejo o sobro delo que comió el niño o niña).
8. Que hizo lo que sobro? (se refiere a lo que sobro en la familia y lo que dejo el niño o niña). Esta pregunta
no aparece en el formulario pero siempre que hay sobrantes debe hacerse y anotarse en observaciones.
Siempre pregunte por las pachas que consume el niño o niña seleccionando. Si la respuesta es afirmativa,
anote que si consume en el espacio de “observaciones” para no olvidar preguntar durante la entrevista a qué
horas le da pacha, refacción de la mañana, almuerzo, entre otros. Si alguna refacción se da en la madrugada,
anótela como parte del desayuno, y si le da durante la noche, anótela como parte de la cena.
Después de obtener la información a través de la entrevista, deberá llenar en la oficina las siguientes
columnas en este orden:
1. Número de unidades (columna 7).
2. Código de la unidad de medida (columna 8).
3. Peso de la medida en gramos ml (columna 9): cuando se utiliza el listado de pesos.
4. Código de los alimentos (columna 3).
5. Tiempo de comida (columna 2).
A continuación se indica la forma de llenar cada una de las columnas:
Columna 1: Nombre del alimento o de la preparación
Alimento solo: Un alimento puede codificarse como alimento solo en el caso de piña, papaya, pan o
también cuando se ha obtenido previamente la receta y se determina la composición nutricional de esta.
Para nuestro caso, se contara como alimentos solos las siguientes preparaciones dado que se cuenta con
recetas promedio:
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- Frijol cocido.
La pregunta que le hará a la entrevistada puede ser: “Sra., cuénteme ¿Qué preparo o que comieron el día de
ayer en el desayuno?
Primero escriba en esta columna el tiempo de comida al que corresponden las preparaciones o alimentos,
Por ej. Desayuno, luego anote el nombre de todas las preparaciones o alimentos, dejando en blanco espacios
suficientes entre cada preparación para anotar luego en la columna 5 todos los ingredientes usados en la
preparación, Trate de obtener los nombres completos de las preparaciones.
Apunte todo lo que prepararon y comieron para el desayuno DEJANDO SUFICIENTESESPACIO, NO SE
PREOCUPEPOR DEJAR LINEAS EN BLNACO, la revisión del formulario y el ingreso de datos va a
hacer mucho más fácil si deja espacios entre preparaciones y alimentos.
Columna 2: Tiempo (tiempo de comida)
Esta columna se refiere al tiempo de comida que corresponden los alimentos y preparaciones de la columna
1. Las comidas consumidas antes del desayuno se toma como parte del desayuno, por ejemplo las pachas
que se dan en la madrugada. Las comidas consumidas después de la cena se toman como parte de la cena.
El tiempo será definido según lo considera la entrevistada, sin tomar en cuenta la hora.
1. Desayuno.
2. Refacción de la mañana.
3. Almuerzo.
4. Refacción de la tarde.
5. Cena o comida.
Esta columna puede ser llenada simultáneamente o después de la entrevista, por lo que es importante
escribir el tiempo de la comida en la columna 1. Se usara 1 digito o sea, un numero entero (X) en esta
columna.
No debe quedar preparación o alimento sin código de tiempo de comida.
Columna 3: Código
Aquí se anotara los códigos de los alimentos que corresponden a cada ingrediente que esta anotado en la
columna 5. El código de cada alimento siempre estará expresado con 5digitosque corresponden a la tabla
de Composición de Alimentos de Centroamérica. Esta columna será llenada en la oficina. Tenga especial
cuidado si el alimento esta en crudo o en cocido, con cascara o sin cascara.
Columna 4: En el formulario, esta columna tiene impresos los números del 1-18, esto indica el número de
líneas en la hoja. No escriba nada en esta columna, esto sirve para facilitar el ingreso de datos en el Centro
de Cómputo.
Columna 5: Nombre del alimento
Durante la entrevista se preguntara ¿Qué alimentos uso para la preparación? Y escriba en esta columna
todos los ingredientes o alimentos que se utilizaron en cada preparación. Observe que en esta columna
también se anotan las características de cada ingrediente o alimento como por ejemplo: clase, variedad,
tipo, color, tamaño, marca, crudo, cocido, con cascara o sin cascara. Anotarlas características de todos los
ingredientes es importante porque es lo que permite su posterior codificación, si no lo hace se convierte en
un serio problema cuando se codifique los alimentos.
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Los siguientes son ejemplos del tipo de información necesaria para poder codificar un alimento:
Leches: liquida o en polvo.
Integra, descremada, deslactosada, condensada o evaporada, marca.
Quesos: Blanco fresco o duro, amarillo, cuajada, crema mozarela, de capas y otros tipos.
Carnes: Res, cerdo, pollo, pescado u otro animal.
Con o sin hueso, con o sin piel, con o sin grasa.
Frijoles: Indicar el color y variedad.
Preparación: cocidos, arreglados o molidos.
Verduras y frutas: Madura, verde, con o sin cascara, tamaño, color y variedad en caso que sea
necesario.
Arroz: Arroz corriente o precocido.
Panes: Dulce, francés, precio o el tamaño.
Galletas: Dulce o salada, con o sin relleno, tamaño del paquete, marca.
Grasas: Manteca vegetal o de cerdo, tipo de aceite, mantequilla
Bebidas: Diferenciar entre refresco embotellado tipo cola y otros, si son o no light
Alimentos enlatados: Escribir el nombre completo del producto, tamaño y marca.
Cuando pregunte por ingredientes de una preparación frita no olvide registrar manteca, aceite u otra grasa,
también cuando se trate de preparaciones dulces no olvide registrar azúcar, tapa de dulce o miel; en
preparaciones saladas preguntar por la sal. Si estos ingredientes no han sido usados debe indicarlo en
observaciones.
Los condimentos secos y frescos que se utilicen en pequeñas cantidades no se deben registrar.
Recuerde que en el caso de frijoles cocidos, arreglados o molidos, arroz frito, gallo pinto no
necesitan conocer los ingredientes y cantidades, puesto que se consideran como alimento solo,
interesa Sololá cantidad que se sirvieron y consumieron.
Columna 6: Cantidad unidades caseras
Esta columna se refiere a las cantidades utilizadas de cada alimento para hacer la preparación, expresadas
en medidas caseras, unidades de compra, entre otros. Cuando se pregunte este dato, ya se tendrá anotados
todos los ingredientes y se preguntara: Sra. ¿Cuánto uso de __________ (mencione cada uno de los
ingredientes)?. La cantidad se anota en la línea de cada ingrediente, en las medidas que indica la entrevistada
que puede ser: 2Cucharadas rasas o copetonas, 3 tazas, 2 unidades (pequeña mediana, grande). En el caso
de cuchara, cucharita y cucharon verifique la unidad de medida con los modelos.
En esta columna, debe aparecer suficiente información que ayude a llenar las columnas 7, 8 y 9. Para el
registro de la unidad de medida es necesario que utilice las abreviaturas que aparecen en el Cuadro 1 con
el fin de estandarizar la forma de anotación.
CUADRO 1. Abreviaturas de unidad de medidas
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Unidad de medida Abreviatura Unidad de medida Abreviatura
Onza OZ Medida Med
Kilogramo Kg Porción P
Gramo Gr Rollo Rol
Litro Lt Pieza Pza
Botella Bot Frasco Fco
Cucharada grande Cda g Bolsa B
Cucharada Sopera Cda Sobre S
Cucharita Cdta Lata L
Taza T Barra Bar
Vaso V Paquete Paq
Unidad U Pedazo Pzo
Unidad pequeña U p Poco Poco
Unidad mediana Um Rodaja Rod
Unidad grande Ug Chorrito Chto
Madura mad
Consumo familiar
Columna 7: Número de unidades
En esta columna trasladara la información que anoto en la columna 6, usando solamente números: dos
enteros y dos decimales (XX.XX), sin anotar las unidades de medida. Recuerde que estos datos son los que
se digitaran en el centro de cómputo.
Por ejemplo “Si la señora estima que uso 2 cdas. De cierto tamaño según el modelo, se anota el número
02.00 para indicar que fueron 2 veces la cantidad de la cuchara.
Esta columna será llenada en la oficina.
Columna 8: Código de la medida
La información registrada en la columna 6 que se refiere a la unidad de medida, se codificara utilizando
códigos específicos, con 2 números enteros (XX). Algunas veces esta columna se llena simultáneamente
con la Columna 6.
Para estimar el tamaño de las tortillas hechas en casa, averiguar el tamaño para el adulto y el niño preescolar,
si fueron del mismo tamaño pesar al menos 3 unidades y obtener el peso promedio. En caso de que no sean
del mismo tamaño obtenga un peso promedio de cada una.
Los códigos a utilizar en esta columna son los siguientes:
01: Unidad
02: Onza fluida.
03: Chorrito.
04: Unidad pequeña.
05: Unidad mediana.
06: Unidad grande
07: cucharadita rasa.
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08: Cucharadita copetona.
09: Cucharada rasa.
10: Cucharada copetona.
11: Cucharoncito raso.
12: Cucharoncito copetón.
13: Cucharon raso.
14: Cucharon copetón.
15: Bolsa
16: Libra.
17: Rama.
18: Manojo.
19: Botella.
20: Sobre.
21: Puñito.
Columna 9: Peso de la medida en gr o ml
En esta columna se registra el peso de los alimentos con 4 números enteros. Estos pesos deben escribirse
únicamente cuando en la columna 8 aparecen los códigos 1 0 3. Si usa los códigos 2,4 al 19, la columna 9
deben quedar en blanco.
Columna 10: No. total de porciones
Antes de determinar el número total de porciones se pregunta si el niño o niña comió de esta preparación o
sobro. Si el niño o niña no consumió ni sobro nada, deje esta columna en blanco y solo anote en la columna
11 y 12 un cero (0).
Para obtener esta información es necesario saber cuántas porciones salieron y si todas fueron del mismo
tamaño.
Por ejemplo: “Sra., de los macarrones ¿Cuántas porciones, platos, tazas o cucharadas le salieron?” “¿Todas
las porciones fueron del mismo tamaño?”. Si todas las porciones fueron del mismo tamaño anote el número
indicado.
En el caso de que las porciones no fueron del mismo tamaño, pregunte por ejemplo: ¿Ud. Cuánto comió?
¿Y su esposo? La respuesta puede ser: la señora una porción, su esposo el doble y su hijo una porción de la
mitad de la de ella. En este caso, el número total seria 3.5 porciones.
En esta columna se anota el número total de porciones con2 números enteros y 2 decimales (XX.XX). Así
en el ejemplo anterior se anotaría 03.50.
Cuando en una preparación el número de porciones es igual para todos los ingredientes, trace una flecha
desde el segundo ingrediente hasta el último. Esto evitara escribir la misma información para todos los
ingredientes.
En caso de preparaciones que sobraron de otro tiempo de comida anote nuevamente toda la
información desde la columna 1 hasta la columna 10.
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Columna 11: Porciones no consumidas
La pregunta que se formula a la entrevistada es: “Sra., ¿de lo que preparo le sobro o se lo comieron todo?
Se anota en esta columna lo que sobro de la preparación (a nivel de la familia), usando 2 números enteros
y 2 decimales (XX.XX). La cantidad que se anota debe tener la misma unidad de medida de las porciones
registradas en la columna 10, si no sobro anote un cero (0).
Cuando se trate de sobrante de preparaciones elaboradas en otro tiempo de comida se debe anotar lo que se
consumió en ese tiempo de comida más lo que volvió a sobrar.
Cuando existen sobrantes, debe anotar en “observaciones” que paso con el sobrante.
Consumo del niño y niña de 0 a 23 meses de edad
Columna 12: Cantidad servida
Aquí se anota la cantidad de porciones consumidas por el escolar. Se anota la información en la misma
unidad de medida de la columna 10 y en la misma línea donde se anotó el número de porciones de la familia;
use dos números enteros y dos decimales (XX.XX).
Por ejemplo se pregunta: “¿Señora, Carlitos comió macarrones”?. Si la respuesta es NO, escriba cero en la
columna y continúe preguntando la siguiente preparación o alimento anotados en la columna 1. Si comió
pregunte “¿Cuánto comió?”. El tamaño de la porción servida debe tener relación con el tamaño de la porción
anotada en la columna 10.
Por ejemplo pregunte: “¿Del tamaño de la porción que se sirvió Ud. Cuando le sirvió al niño o niña?”.
Pregunte si la entrevistada le sirvió a toda la familia con la misma unidad o con el mismo modelo, si se trata
de preparaciones y al niño o niña le sirvieron diferente unidad de medida sebe preguntar “De una porción
de la familia ¿Cuántas salen del niño o niña?. Cuando se trate de alimentos y la medida del niño o niña es
diferente al resto de la familia, abra otra línea para anotar el mismo alimento con el código de la medida
correspondiente. Por ejemplo: la mama le sirvió frijoles a los adultos 3 cucharas de servir de teflón rasas
(No. 16), pero al niño le sirvió dos cucharas soperas copetonas (No. 13), entonces anote en dos líneas
diferentes esta información.
Columna 13: Sobras
Se pregunta: “¿De la cantidad que le sirvió al niño o niña, se lo comió todo o dejo algo?”. Se anota la
cantidad de comida que sobro, usando 2 números enteros y 2 decimales (XX.XX), se anota cero cuando la
cantidad servid se consumió toda. En el caso que no hubo consumo, esta columna queda en blanco. Si sobro
anote en observaciones el uso que se le dio al sobrante.
Se puede presentar diferentes casos en donde sobran alimentos:
1. El niño y/o niña no consumió todo y lo botaron o lo dieron a los animales. En este caso se anota la
cantidad en la columna de cantidad servida y se escribe lo que sobro, sin hacer cambios en lo que
se escribió en ninguna de las columnas.
2. El niño y/o niña no consumió todo, y otra persona se lo comió. Se resta la cantidad que no comió
el niño y/o niña a la porción servida, y se escribe en la columna 12 lo que en realidad se comió. En
la columna de sobras se anota un cero. No debe hacer ningún otro cambio. Por ejemplo, si la madre
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comió la mitad de la tortilla de su hijo, en la columna de cantidad servida al niño pondrá 00.50 y
en la columna de sobras del niño y/o niña escribirá un 0.
3. El niño y/o niña seleccionado no consumió todo y lo dejaron para comer en otro tiempo de comida.
Se resta de la cantidad servida al niño y/o niña lo que él no comió y en la columna de “sobras”
anote un cero y escriba el sobrante en las raciones no consumidas de la familia (columna 11).
Observaciones
Anote cualquier información que estima de importancia para el supervisor equipo de campo o para aclarar
algún aspecto de la encuesta.
3. COMO ANOTAR CASOS ESPECIALES EN LOS FORMULARIOS
Preparaciones en las que no se puede dividir en un número igual de porciones todos los ingredientes Existen preparaciones que llevan varios ingredientes que se dividen o se cortan en diferentes tamaños o
porciones, como son los caldos. En algunos casos el niño o niña no come alguno de estos ingredientes, por
lo general verduras o carnes, o también el tamaño de las porciones en las que se dividieron el caldo. En
estos casos todos estos ingredientes deben anotarse COMO ALIMENTOS INDIVIDUALES. Para cada
alimento se anotara el NUMERO TOTAL DE PORCIONES Y PORCIONES NO CONSUMIDAS de
la familia.
De igual forma, se procede con la cantidad servida y las sobras del niño o niña. Si este no come de un
ingrediente, anote un cero en la columna de cantidad servida en la línea que corresponde al ingrediente no
consumida.
Cuando en un picadillo o caldo, se corta los ingredientes en trozos muy pequeños de manera que no se
puede contar, en este caso la porción de líquido será la misma de los demás ingredientes y puede
considerarlo como preparación.
Frijoles cocidos
En el caso de estas preparaciones, solamente se preguntara por lo consumido y no por lo preparado.
Solamente si es una preparación especial que lleve otros ingredientes como carne, chorizos, costilla, pollo
o verduras se debe preguntar la receta. Tenga mucho cuidado al utilizar el código de arroz y frijol crudo o
cocido según sea el caso.
Únicamente buscara el peso de la medida que exprese la madre.
Volumen de líquidos o bebidas
Se debe medir el volumen de líquido cuando:
1. En la dieta familiar hubo sobrante o hubo consumo del niño o niña y la persona entrevistada no
puede estimar el número total de porciones.
2. La persona entrevistada no puede estimar en mililitros la cantidad servida al niño y o niña.
4. REVISION DE LOS FORMULAROPS EN EL CAMPO
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Los formularios serán revisados en el campo con el propósito de verificar que se tomó toda la información
necesaria y que no hay dudas sobre cantidades de alimentos. Las correcciones realizadas por el supervisor(a)
del equipo de campo se deben realizar con lapicero rojo.
Para la revisión se deben considerar los siguientes aspectos:
Formulario de consumo de alimentos
Verifique que en todas las hojas, los datos de identificación sea la misma y que las hojas estén
numeradas y completas, para todas las hojas que se utilicen.
Revise que los alimentos anotados en la columna 5 tengan los nombres completos y que concuerden
con el nombre de la preparación indicada, ejemplo: carne sin o con hueso, frutas maduras o verdes,
color del chile dulce, tipo de grasa utilizada en preparaciones fritas, azúcar para preparaciones
dulces, ingredientes par salar, otros.
Revise que en la columna 6 aparezca las cantidades con su respectiva unidad de medida. De acuerdo
al tamaño de la familia revise si las cantidades anotadas son lógicas.
Verifique si sobro alguna preparación y cuál fue su destino.
En el consumo del niño o niña verifique que las porciones expresadas tengan la misma unidad que
la medida del consumo familiar.
Especialmente en el caso del niño o niña revise con mucha atención el consumo de todo el día para
asegurarse si no se omitió algún tiempo de comida. Si comió muy poco o si el consumo parece
demasiado alto.
5. REVISION DE LOS FORMULARIOS EN LA OFICINA, ANTES DE SER DIGITADOS
En esta etapa se verifica que todos los datos y las codificaciones se encuentren correctos. Esta es la etapa
previa a la digitación, por lo tanto, la revisión debe ser muy cuidadosa para evitar mayores correcciones y
ajustes durante la limpieza final. Las correcciones se deben realizar con lapicero azul.
Formulario de consumo de alimentos
Encabezado
Verificar que en el encabezado de cada hoja:
Códigos de identificación.
Numero de hoja.
Fecha de recolección de datos.
Preparación
Revisar que todas las preparaciones y alimentos tengan código para tiempo de comida.
Alimentos usados
Revisar que los alimentos registrados en la columna 5 tengan código correcto anotado en la
columna 3.
Revisar que las preparaciones fritas tengan registrada la grasa.
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Revisar que las preparaciones dulces tengan registrado el ingrediente para endulzar.
Revisar que las preparaciones saladas tengan registradas el ingrediente utilizado para salar.
Consumo familiar
Analizar en función del número de personas en el hogar las cantidades de alimentos. Revisar que la columna
7 tenga anotada la información para todos los alimentos.
Consumo del niño y/o niña
Revisar que exista proporción entre las cantidades reportadas en las columnas 12 y 10.
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Appendix 37. Market Prices Survey Form
Instituto de Nutrición de Centro América y Panamá, FANTA III/FHI360 Information Gathering Activity (OPTIFOOD) August 2012
Market Prices Survey Form
Sale Place (Market name)
Location, municipality
Surveyor´s name ID code
Reviewed by Supervisor ID code
Survey´s date dd/mm/yyyy
Food item code
Food name Measure
Unit for sale
Weight (g) PRICE
1 2 3 Average 1 2 3 4 5 Average
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